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If your health status changes in the future, please let us know. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis(assessment) or treatment. you will be asked to provide written authorization for release of any information.  \n\n| Is this injury due to a motor vehicle or work-related accident? | ☐ Yes ☐ No |\n| --- | --- |\n| Chief Complaint |  |\n| General Health Status | ☐ Excellent ☐ Good ☐ Fair ☐ Poor |\n| Please indicate the conditions you are experiencing or have experienced. | Respiratory\u003Cbr>☐ Chronic cough ☐ Shortness of breath ☐ Bronchitis ☐ Asthma ☐ Emphysema ☐ Family History?\u003Cbr>Cardiovascular\u003Cbr>☐ High Blood Pressure ☐ Heart Attack\u003Cbr>☐ Pacemaker or similar device\u003Cbr>☐ Low Blood Pressure ☐ Phlebitis/vericaose veins ☐ Heart disease ☐ CCHF ☐ Stroke/CVA ☐ Family History?\u003Cbr>Head/Neck\u003Cbr>☐ Vision problems ☐ Vision loss ☐ Ear problems ☐ Hearing loss ☐ Headaches/migraines\u003Cbr>Infections\u003Cbr>☐ Hepatitis ☐ Skin conditions ☐ Respiratory conditions ☐ HIV ☐ Herpes\u003Cbr>Other Conditions\u003Cbr>☐ Loss of sensation ☐ Diabetes ☐ Allergies ☐ Epilepsy ☐ Cancer ☐ Arthritis\u003Cbr>Women-Pregnant?\u003Cbr>☐ Yes ☐ No\u003Cbr>Soft Tissue/Joint Discomfort\u003Cbr>☐ Neck ☐ Upper Back ☐ Mid Back ☐ Low Back ☐ Shoulders ☐ Arms ☐ Legs ☐ Knees ☐ Other\u003Cbr>Other Medical Conditions?\u003Cbr>☐ YES |\n\n1  \n\n| Medications |  |\n| --- | --- |\n| Previous/Upcoming Surgeries |  |\n| Present involvement in other healthcare? | ☐ Physical Therapy ☐ Massage Therapy ☐ Chiropractor ☐ Acupuncture ☐ Osteopathy ☐ Personal Trainer ☐ Nutritionalist ☐ Other |\n\nInformed Consent  \n☐ I am aware of the fees for physical therapy assessment and treatment. I hereby consent to treatment by the attending therapist. All information in my file will be kept confidential, although the file will be shared among any treating therapists and/or practitioners in this clinic. I understand that written authorization will be obtained prior to any release of information, except when required by a court of law.  \nThis template was adapted from a real intake form used by physical therapists on Jane. Customize it to reflect your practice's policies, branding, jurisdiction, and scope of practice.  \n2","cbCaipdGTf2fXH5l","https://ap.wps.com/l/cbCaipdGTf2fXH5l","pdf",125494,"English","# Health History Intake Details\n## Injury, Health Status, and Conditions\n## Medications and Surgeries\n## Other Healthcare Involvement\n## Informed Consent","[{\"question\":\"What information does the form ask the patient to report?\",\"answer\":\"The form collects injury details, general health status, experienced conditions across multiple body systems, areas of discomfort, medications, surgeries, and whether the patient is involved with other healthcare services. It also includes an informed consent acknowledgment for assessment and treatment fees.\"}]","Health History Intake Form - Consent and Medical Questionnaire | PDF",1789851995]