Rancho Physical Therapy | Patient Forms

Have you suffered from any illnesses not listed above? Yes No

If yes, please explain:

Have you ever had surgery including this current condition? Yes No

If yes, please list the type of surgery and the year it was done:

Type:  Date:
Type:  Date:
Type:  Date:
Type:  Date:

Have you had therapy for your current condition? Yes No

If yes, please list:

Location: Dates:
# of Visits:

Please list any medications or herbal supplements you are currently taking:

Type: Dosage:
Type: Dosage:
Type: Dosage:
Type: Dosage:
Type: Dosage:
Type: Dosage:

What body part are we treating?

Are we treating you as a result of a fall? Yes No

Have you fallen twice or more in the last year? Yes No

Describe the history of your present condition. Please provide all important details.

What are your goals or expectations of therapy?

Patient: Date of Birth:

Please remember to sign and date your printout.