Graston Technique Provider
 
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Patient Forms - New Patient Form
 

You can download the New Patient Form here: New Patient Form

If you prefer, you can complete the New Patient Form below.

Click here to return to list of all forms.

 
 
New Patient Medical History Information

 

 
 
What problems are you being treated for today?
 
When did your problems begin?
 
How did your problems begin?
 
Have you had any surgeries related to this problem? Yes No
 

If yes, type of surgery and date:

 
Have you received treatment of these symptoms? Yes No
 
 

 
Are you currently receiving Home Health Care Services? Yes No
 
(You cannot receive home health care services and outpatient therapy services concurrently under Medicare rules).
 
Have you ever received outpatient Physical Therapy for this condition? Yes No
 
 

 
Are you currently working? Yes No
 

If you are working, what is your occupation?

 

Does your occupation consist of (check all that apply):

Sitting Standing Walking Lifting Driving

 

 
Are you currently taking any medications? Yes No
 

If yes, please list medications

 

If you have pain, what is the current level of pain?

On a scale from 0 to 10, 0 being no pain, 10 being worst possible pain

0 1 2 3 4 5 6 7 8 9 10

 

Do you have any known allergies to drugs? Yes No
 

If yes, please list your allergies:

 

What kind of diagnostic tests, if any, have you had for this problem? X-ray MRI Bone Scan CT Scan Blood Tests

 

Please check the boxes next to any conditions that you have experienced in the past.

Bone and Joint Disease Tendonitis /bursitis Fractures Arthritis Muscle spasms Low back, hip, leg pain Low back, hip, leg pain Cancer/tumors Lupus AIDS/HIV Diabetes Heart conditions Thyroid Problems Lymphedema Kidney problems Irritable Bowel Syndrome Herpes/shingles Sleep Disorders Depression Psychological issues Eating Disorder Drug/alcohol addiction Nicotine/caffeine addiction
 
Hypoglycemia Varicose Veins Blood clots Breathing difficulties/asthma High Blood Pressure Low Blood Pressure Pacemaker Metal Implants Are you pregnant? Sprains/ strains Rashes Athlete's foot Warts Headaches/head injuries Bladder problems Urinary Tract Infections Nausea/vomiting Numbness/tingling Fatigue Seizures Seizures Chest Pain
 

Please check the boxes next to any conditions that you have currently.

Bone and Joint Disease Tendonitis /bursitis Fractures Arthritis Muscle spasms Low back, hip, leg pain Neck, Shoulder, Arm Pain Cancer/tumors Lupus AIDS/HIV Diabetes Heart conditions Thyroid Problems Lymphedema Kidney problems Irritable Bowel Syndrome Herpes/shingles Sleep Disorders Depression Psychological issues Eating Disorder Drug/alcohol addiction Nicotine/caffeine addiction
Hypoglycemia Varicose Veins Blood clots Breathing difficulties/asthma High Blood Pressure Low Blood Pressure Pacemaker Metal Implants Are you pregnant? Sprains/ strains Rashes Athlete’s foot Warts Headaches/head injuries Bladder problems Urinary Tract Infections Nausea/vomiting Numbness/tingling Fatigue Seizures Seizures Chest Pain
 
 
 
If you checked any of the above, conditions you've experiened in the past or present, please provide details below:
 
Is there any additional information that we should be aware of to make your rehabilitation easier?
 
 
What is your goal in therapy?
 
What is your living condition? Do you live alone?