New Patient Forms Health History QuestionnaireName* First Last Date of Birth* Referring Physician*Date of last physical exam Current Medications click + button to right of input to add multiplePlease check all that apply & comment where applicable:Recent Illness Recent Illness ExplainRecent Hospitalization Recent Hospitalization Dates/diagnosisSurgical history (fractures, joint replacements, etc.) Surgical history (fractures, joint replacements, etc.) DetailsHeart condition(s) Heart condition(s) DetailsHas your doctor ever said that you should only do physical activity recommended by a doctor?YesNoLung Disease Lung Disease DetailsDiabetes Mellitus Diabetes Mellitus Controlled with medication diet High blood pressure High blood pressure controlled with medication?Arthritis Arthritis joints involvedChronic Pain Chronic Pain DetailsDizziness Dizziness DetailsCurrent Exercise Program Current Exercise Program DetailsOther Other CommentsPlease tell us about your painDate of onset* Describe location of pain*Please rate your pain*0 = Least | 10 = Worst012345678910Have you received any prior treatment for this problem? (injections, prior therapy, chiropractic, etc.)How did you choose Friendship Outpatient & Wellness Services for your therapy needs?*To help us better serve you, please answer these question as wellIs transportation a problem for you?YesNoDoes your illness/injury limit your work or leisure activities?YesNoDo you have a spouse or children depending on you?YesNoDo you have family or friends that can help you if needed?YesNoHave you had any major losses in the past year?YesNoWould you like information about resources in the community that could assist with your recovery?YesNoWould you like our Social Worker to call you or meet with you?YesNoUpload Signed DocumentsThese forms can be downloaded in Form Downloads section at the bottom of this page.FH Outpatient HIPPA PolicyOutpatient Pool GuidelinesOutpatient Therapy AgreementAdditional Patient CommentsFOWS StaffDate This iframe contains the logic required to handle Ajax powered Gravity Forms.