Salem Rehabilitation Associates

Welcome new patients! Let the healing begin

New patients are asked to allow 60-90 minutes for appointments. This includes registration and the doctor’s evaluation. Medical history forms must be submitted a minimum of 3 days prior to your appointment date.

At your first appointment, bring your current insurance information and government-issues photo ID, this could be your driver’s license.

Co-payments are due at the time of your visit, a service fee will be added to your account if you are unable to make the payment at time of service. For your convenience, we accept cash, personal checks, Visa, MasterCard, and Discover.

Medical History Form

Appointment Date*
Month
Day
Year
Appointment Time*

: Hours

Minutes

AM/PM
Name*
First Last
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Date of Injury or Onset of Problem
Month
Day
Year
Date of Surgery (if applicable)
Month
Day
Year
Briefly describe the problem you were referred for:
If you have had this problem before, enter the date that you previously had the problem:
Month
Day
Year
What specific activities, positions, or movements worsen your symptoms?
What reduces your symptoms?
On a scale of 0 to 10 (0 being no pain and 10 being pain so severe that death or permanent impairment must occur within a few minutes), how would you rate your pain?
Medication Information
Do you currently take any medications?*
- Yes
- No
Please list your current medication and supplements. It is important that you include your dose and frequency.
Medication Dose Times per day
Please list any allergies to medications and your adverse reaction to the medication:
Medication Reaction(s)
Review of Systems
Please review the following and indicate all that apply:
Constitutional:
- Activity change
- Chill/shakes
- Decreased appetite
- Fatigue
- Fever
- Insomnia
- Weight gain
- Weight loss
- Irritability
- Weakness
- Lethargy (decreased energy)
- Night sweats
- Malaise (vague feeling of discomfort)
Describe weight gain:
Describe weight loss:
Head, Ears, Eyes & Throat
- Headache
- Visual changes
- Double vision
- Decreased vision
- Spots, flashing, etc.
- Hard of hearing
- Tinnitus (ringing in ears)
- Choking
- Difficulty swallowing liquids
- Difficulty swallowing solids
- Change in voice
Describe headache:
Describe change in voice:
Respiratory/Thorax
- Pleuritic pain (painful breathing)
- Shortness of breath
- Wheezing
Cardiovascular
Chest pain with:
- Exertion
- Resting
- Both
Location of chest pain:
Edema (swelling) of:
- Hands
- Feet
Palpitations (irregular heart beat):
- Yes
- No
Vascular
- Claudication (pain in legs or buttocks with walking)
- Cyanosis (purple or dark blue feet)
- Erythema (redness of limbs)
- Ulcers (sores on feet)
- Blood Clots
Location of cyanosis:
Location of erythema:
Location of and when blood clots occurred:
Gastrointestinal
- Abdominal pain
- Black stools
- Altered bowel habits
Describe altered bowel habits:
Genitourinary
- Dysuria (painful urination)
- Hematuria (blood in urine)
- Increased frequency of urination
- Incontinence (inability to control urine excretion)
- Increased urgency
Frequency of urination:
Metabolic/Endocrine
- Cold intolerance
- Heat intolerance
- Hair loss
- Coarse hair
- Change in sleep/wake cycle
- Generalized weakness
- Polydipsia (excessive thirst)
- Polyphagia (excessive hunger)
Neurology/Psychology
- Difficulty speaking
- Aphasia (difficulty finding words or use of wrong or nonsense words)
- Dysarthria (difficulty pronouncing words)
- Gait (walking) disturbance
- Incoordination
- Paresthesias (numbness/tingling)
- Lightheadedness/Dizziness
- Fainting spells
- Vertigo (sense of room spinning)
- Irritable
- Frequently tearful
- Decreased sense of self-worth
- Feelings of guilt
- Loss of pleasure
- Decreased energy
- Thoughts of harming yourself or others
Describe gait:
Location of incoordination:
Location of paresthesias:
Focal Weakness in:
Leg
Arm
Face
Dermatologic
- Hair changes
- Nail changes
- Pruritis (itching)
- Rash
Description of hair changes:
Description of nail changes:
Location of rash:
Description of rash:
Hematologic
- Easy bruising
- Bleeding problems
- Lymphadenopathy (swollen glands)
Description of bleeding problems:
Musculoskeletal
- Back pain
- Neck pain
- Myalgias (muscle pain)
- Rheumatologic manifestations (hot/red/swollen joints)
Location of back pain:*
Location of back pain:
Joint pain in:
Shoulder
Elbow
Wrist
Fingers
Hip
Knee
Ankle
Feet/Toes
Immunological
- Allergy to tape
- Allergy to latex
- Other
Description of other allergy:
Past Medical & Family History
Adopted or unknown medical history:
- Adopted or unknown family history
Have you or a family member ever been diagnosed with the following?
Rheumatological
Rheumatoid Arthritis:
- You
- Father
- Mother
- Brother
- Sister
Osteoarthritis:
- You
- Father
- Mother
- Brother
- Sister
Psoariatic Arthritis:
- You
- Father
- Mother
- Brother
- Sister
Lupus:
- You
- Father
- Mother
- Brother
- Sister
Vasculitis:
- You
- Father
- Mother
- Brother
- Sister
Other rheumatological disease:
Other rheumatological disease persons:
- You
- Father
- Mother
- Brother
- Sister
Cancer
Cancer
Individual with cancer:
- You
- Father
- Mother
- Brother
- Sister
Cancer
Individual with cancer:
- You
- Father
- Mother
- Brother
- Sister
Cancer
Individual with cancer:
- You
- Father
- Mother
- Brother
- Sister
Cancer
Individual with cancer:
- You
- Father
- Mother
- Brother
- Sister
Cancer
Individual with cancer:
- You
- Father
- Mother
- Brother
- Sister
Heart/Vascular Disease
Heart attack:
- You
- Father
- Mother
- Brother
- Sister
Bypass surgery:
- You
- Father
- Mother
- Brother
- Sister
Coronary artery disease:
- You
- Father
- Mother
- Brother
- Sister
High blood pressure:
- You
- Father
- Mother
- Brother
- Sister
Anemia:
- You
- Father
- Mother
- Brother
- Sister
Lung Disease
COPD:
- You
- Father
- Mother
- Brother
- Sister
Asthma:
- You
- Father
- Mother
- Brother
- Sister
Bronchitis:
- You
- Father
- Mother
- Brother
- Sister
Other lung disease:
Other lung disease persons:
- You
- Father
- Mother
- Brother
- Sister
Endocrine
Diabetes Diagnosis date:
Month
Day
Year
Diabetics:
- You
- Father
- Mother
- Brother
- Sister
Thyroid disease:
- You
- Father
- Mother
- Brother
- Sister
Osteoporosis:
- You
- Father
- Mother
- Brother
- Sister
Gastrointestinal
Stomach ulcer:
- You
- Father
- Mother
- Brother
- Sister
GERD/Gastritis (heartburn):
- You
- Father
- Mother
- Brother
- Sister
Liver Disease
Hepatitis A:
- You
- Father
- Mother
- Brother
- Sister
Hepatitis B:
- You
- Father
- Mother
- Brother
- Sister
Hepatitis C:
- You
- Father
- Mother
- Brother
- Sister
Cirrhosis:
- You
- Father
- Mother
- Brother
- Sister
Other liver disease:
Other liver disease persons:
- You
- Father
- Mother
- Brother
- Sister
Kidney Disease
Renal failure:
- You
- Father
- Mother
- Brother
- Sister
Stones:
- You
- Father
- Mother
- Brother
- Sister
Other kidney disease:
Other kidney disease persons:
- You
- Father
- Mother
- Brother
- Sister
Neurological
Stroke:
- You
- Father
- Mother
- Brother
- Sister
Multiple sclerosis:
- You
- Father
- Mother
- Brother
- Sister
Seizure disorder:
- You
- Father
- Mother
- Brother
- Sister
Peripheral neuropathy:
- You
- Father
- Mother
- Brother
- Sister
Carpal tunnel syndrome:
- You
- Father
- Mother
- Brother
- Sister
Alzheimer's disease:
- You
- Father
- Mother
- Brother
- Sister
Dementia:
- You
- Father
- Mother
- Brother
- Sister
Psychiatric
Depression:
- You
- Father
- Mother
- Brother
- Sister
Bipolar disorder:
- You
- Father
- Mother
- Brother
- Sister
Schizophrenia:
- You
- Father
- Mother
- Brother
- Sister
Personality disorder:
- You
- Father
- Mother
- Brother
- Sister
Alcoholism:
- You
- Father
- Mother
- Brother
- Sister
Drug abuse - Which drug(s):
Drug abuse persons:
- You
- Father
- Mother
- Brother
- Sister
Have you ever had any of the following:
Herniated disk in:
- Cervical (neck) region
- Lumbar (low back) region
Surgery date:
Month
Day
Year
Fractured spine in:
- Cervical
- Thoracic (mid back)
- Lumbar
Surgery date:
Month
Day
Year
Injury to joints:
Shoulder:
Elbow:
Wrist:
Knee:
Other:
Please list any surgeries that you have had:
Surgeries
Surgery Date of Surgery
Is there anything else that you would like the Doctor to know about your health history?
Social History
Primary language spoken:
Dominant hand:
- Left handed
- Right handed
- Ambidextrous
Highest grade completed in school:
Highest degree/diploma completed:
Employer:
Occupation:
Employment status:
- Unemployed
- Disabled
- Retired
Date last worked:
Month
Day
Year
Retired as of:
Month
Day
Year
Marriage status:
- Married
- Significant other/Partner
- Divorced
- Widowed
- Single
Number of Children
Tobacco
Tobacco Use:
- Current, every day
- Current, some days
- Never
- Quit
Year quit tobacco use:
Type of tobacco:
Alcohol
Do you consume alcohol?
- Yes
- No
Type of Alcohol:
How much:
How often:
Year quit:
I exercise regularly:
- Yes
- No
Exercise type:
Exercise frequency:
Please list any hobbies/leisure activities that you are involved in:
Please check this box if you want a chaperone present during your exam with the Doctor.
- Chaperone requested
Thank you for taking the time to complete this packet.
Phone
This field is for validation purposes and should be left unchanged.

New Patients

Welcome new patients! Let the healing begin

Intake Form

Release of Medical Forms

Privacy Policy

Medical History Form

Medication Information

Review of Systems

Past Medical & Family History

Social History

Contact Us

Hours

Medication	Dose	Times per day

Medication	Reaction(s)

Surgery	Date of Surgery