Patient Health History

Name*

First Last

Date of Birth*

Today's Date*

Referring Doctor:*

PCP:

Other Doctors:

Medical Diagnosis:

Onset of Symptoms:

Surgery Date:

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?

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:

Treatment Contraindication/Precaution:

Subjective Information:

Exercise History:

Previous Medical History:

Current Medical History and Symptoms:

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