PATIENT BRIEF HISTORY FORM Name*DOB* Date Format: DD slash MM slash YYYY Date* Date Format: DD slash MM slash YYYY Do you now have/or have you had any of the following: High Blood Pressure*YesNoParkinsonism*YesNoChest Pain (Angina)*YesNoMultiple Sclerosis*YesNoHeart Attack or Surgery*YesNoBrain Injury*YesNoValvular Heart Problem*YesNoMovement Disorder*YesNoPacemaker/Cardiac Implant*YesNoKidney Problems*YesNoDiabetes*YesNoLiver Problems*YesNoHiatal Hernia*YesNoArthritis*YesNoAllergies*YesNoOsteoporosis*YesNoEmphysema/Bronchitis*YesNoJoint Replacement*YesNoCancer*YesNoReaction to heat/cold*YesNoPeripheral Vascular Disease*YesNoEpilepsy/Seizures*YesNoNeuropathies*YesNoFrequent headaches*YesNoStroke*YesNoWear glasses*YesNoCerebellar problems (Ataxia)*YesNoWear Hearing aids*YesNoAnxiety*YesNoVisual/depth perception*YesNoDepression*YesNoInner Ear Problems*YesNoSleep disturbances*YesNoWeight Loss/Gain*YesNoAddiction*YesNoChanges in Appetite*YesNoThyroid disease*YesNoIncontinence*YesNoTuberculosis*YesNoSpeech Problems*YesNoAsthma*YesNoHepatitis*YesNoCurrently Pregnant*YesNoMetal Implants*YesNoDizzy Spells*YesNoGall Bladder Problem*YesNoFractures*YesNoDeep Vein Thrombosis*YesNoAnemia*YesNoSmoking History*YesNoFall History:1. Have you had any injury due to fall in the past year?*YesNo2. Have you had more than 2 falls in the past year?*YesNoSurgical History:1. Type of surgery:Date: Date Format: DD slash MM slash YYYY 2. Type of surgery:Date: Date Format: DD slash MM slash YYYY 3. Type of surgery:Date: Date Format: DD slash MM slash YYYY 4. Type of surgery:Date: Date Format: DD slash MM slash YYYY Current Medications (Alternatively provide us with a list): Drug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingDrug:Dose:Frequency:Route:Reason for takingPatient Name*DOB* Date Format: MM slash DD slash YYYY Patient Signature*Date* Date Format: DD slash MM slash YYYY
