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Patient Health History
Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Today's Date
*
MM slash DD slash YYYY
Referring Doctor:
*
PCP:
Other Doctors:
Medical Diagnosis:
Onset of Symptoms:
Surgery Date:
MM slash DD slash YYYY
Treatment Contraindication/Precaution:
Do any of the following apply?
*
Cardiac
HTN
Diabetes
Cancer
Pregnant
N/A
Are you comfortable in water:
4 ft.
6 ft.
Do you lose balance in water?
*
No
Yes
Have you experienced any negative effects from:
*
chlorine
exercising in 88-92 degree water
other
If other, please describe:
Subjective Information:
Age:
*
Weight:
*
Height:
*
Vocational Status:
*
N/A
Employed
Not Employed
Retired
Disability
Student
If Unemployed, Last Date of Work?
MM slash DD slash YYYY
If Student, Level?
Employer:
Occupation:
Social/Living Situation:
*
Home
Apartment/Townhouse
Are there stairs where you live? If so, how many?
Animals:
Other:
Family Living with You:
Family Not Living with You:
Exercise History:
Activity Level:
*
sedentary
moderate
extreme
Do you belong to a gym, pool, performing arts center, team, club? If so, where? Doing what? How often?
Do you know of any reason why you should not participate in an exercise program?
*
No
Yes
If yes, please explain:
Has your doctor told you that you have a heart condition and should only do exercise recommended by a doctor?
*
No
Yes
Have you exercised in:
shallow water
deep water
Do you feel pain in your chest when you do:
physical activity
pins and needles
numbness
In the last month have you had:
chest pain at rest
dizziness
loss of consciousness
Previous Medical History:
Medications: (all)
Current or prior smoker?
Yes
No
Smoke / day
How many years have you / did you smoke:
Did you quit?
Yes
No
Have you had any recent weight gain or loss? If so, please describe.
Alcohol intake:
0-7/week
7-14/week
14+/week
If applicable, would you describe your menses as regular or irregular? If irregular, please describe.
Heart:
Blood pressure:
Lung:
Psych:
Cancer:
Diabetes:
Neuropathy:
Dizziness:
Headache:
Blackouts:
Anemia:
Arthritis:
Pace maker:
Cataracts:
Macular degeneration:
Glaucoma:
Glasses/contacts:
Pregnant now:
Allergies:
Other conditions/disorders/illness/surgeries:
Do you have any:
Bladder or bowel incontinence
Open wounds
Infection
Current Medical History and Symptoms:
Do you have any of the following symptoms?
Pain
Spasm
Tingling
Numbness
Weakness
Swelling
Pop/lock/give way
Cramps
Other
If other, please describe:
Where:
How severe:
Constant
Intermittent
Please rate your pain from 1-10 at present:
Please enter a number from
1
to
10
.
Please rate your pain from 1-10 over the last week:
Please enter a number from
1
to
10
.
Made worse by:
Started on:
Is your pain getting:
Better
Worse
Same
Caused by:
Insidious
MVA
Work injury
Other
If other, please describe:
Dr. diagnosed as:
Tests:
Xray
MRI
Other
If other, please describe:
Treatment to date:
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