Looking for the Best Physical Rehab?

Call : +1 (416) 249-8668

Email : info@trinityrehab.ca

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Looking for the Best Physical Rehab?

Call : +1 (416) 249-8668

Email :info@trinityrehab.ca

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About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

About Us
- Who We Are
- Our Team
- Careers
- Gallery
Services
- Core Services
- What We Treat
Patient Center
Contact Us
Blogs

Looking for the Best Physical Rehab?

About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

About Us
Our Services
Patient Center
- Forms
Contact Us
FAQ

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TPh. 416-249-8668, Fax. 416-249-5794, Email:info@trinityrehab.ca
1 723 Kipling Ave. Unit#9, Etobicoke, ON M9R4E1
www.Trinityrehab.ca

HEALTH HISTORY FORM

PERSONAL INFORMATION

Patient’s Name:

Age:

Family Status:

Pulse:

Dominant Side:

Date:

Gender:

Height:

# of Children:

How Often Do you:

Smoke?

Drink?

Exercise?

Date of Birth:

Blood Pressure:

Weight:

Age of Children:

JOB INFORMATION

Job Title:

Returned To Work?

Yes

No

F/T P/T:

Missed Time From Work?

Yes

No

Job Duties:

Sit

Stand

Walk

Lift

Carry

Push

Pull

Bend

Stoop

Squat

Kneel

Reach

Grip

Student:

Returned To Work?

Yes

No

F/T P/T:

Missed Time From Work?

Yes

No

MEDICAL HISTORY:

Blood pressure:

High

Low

High cholesterol:

Yes

No

Heart attack:

Yes

No

Heart disease:

Yes

No

Phlebitis/Varicose veins:

Yes

No

Stroke / CVA:

Yes

No

Pacemaker / Other device:

Yes

No

Chronic neck problems:

Yes

No

Chronic back problems:

Yes

No

Disc bulge/herniation:

Yes

No

Disc degeneration:

Yes

No

Sciatica:

Yes

No

Osteoarthritis:

Yes

No

Rheumatoid arthritis:

Yes

No

Infectious disease

Yes

No

HIV:

Yes

No

Hepatitis (A, B or C):

Yes

No

Ear / Hearing problems:

Yes

No

Eye / Vision Problems:

Yes

No

Ringing in ears:

Yes

No

Are you pregnant?:

Yes

No

Pregnancy Due Date:

Diabetes:

High

Low

Headache:

Yes

No

Dizziness / Vertigo:

Yes

No

Scoliosis:

Yes

No

Fibromyalgia:

Yes

No

Chronic Fatigue:

Yes

No

Asthma:

Yes

No

Bronchitis:

Yes

No

Liver problems:

Yes

No

Chronic cough:

Yes

No

Osteoporosis:

Yes

No

Blood disorders:

Yes

No

Depression:

Yes

No

Anxiety:

Yes

No

Nervousness:

Yes

No

Schizophrenia:

Yes

No

Other:(knee, shoulder, hip, etc)

Kidney problems:

Yes

No

Shortness of breath:

Yes

No

Skin problems:

Yes

No

Allergies / Hypersensitivity:

Yes

No

Cancer:

Yes

No

Unexplained weight loss:

Yes

No

Thyroid problems:

Yes

No

Numbness:

Yes

No

Digestive problems:

Yes

No

Emphysema:

Yes

No

Gynecological condition:

Yes

No

Have you suffered any:

Falls

Head injuries

Broken bones

Dislocations

Work related/Sports injuries

Previous MVA

Surgeries/Hospitalizations

Psychological treatment

Other

Falls Details

Falls Date:

Falls Description:

Head injuries Details

Head injuries Date:

Head injuries Description:

Broken bones Details

Broken bones Date:

Broken bones Description:

Dislocations

Dislocations Date:

Dislocations Description:

Work related/Sports injuries Details

Work related/Sports injuries Date:

Work related/Sports injuries Description:

Previous MVA Details

Previous MVA Date:

Previous MVA Description:

Surgeries/Hospitalizations Details

Surgeries/Hospitalizations Date:

Surgeries/Hospitalizations Description:

Psychological treatment Details

Psychological treatment Date:

Psychological treatment Description:

Other Details

Date:

Description:

CURRENT MEDICATIONS/SUPPLEMENTS LIST

1.Medication Name:

2.Medication Name:

3.Medication Name:

1.Dose:

2.Dose:

3.Dose:

1.What Condition Is It For?:

2.What Condition Is It For?:

3.What Condition Is It For?:

FAMILY MEDICAL HISTORY

1.Condition:

2.Condition:

1.Family Member:

2.Family Member:

PRIOR HISTORY OF CHIEF COMPLAINT(S)

Complaint:

Details/Treatment:

I Hoac, Eva, consent to the review of my health history and also consent to a physical examination to allow my health care providers at Trinity Rehab & Wellness to determine an appropriate program of care.

Patient’s Signature:

Date:

Request an Appointment

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