- Patient Medical History -
Email ID :
Patient Name :
Are you presently working? :
Have you had a related surgery? :
Referring Physician :
Date of Last M.D. Visit :
Date of Injury/Onset of problem :
Dates out of work from injury : to
Type of Surgery :
Family Physician :
Date of Next M.D. Visit :
Are you presently taking any Prescription Medications?
(if yes, please list medications and for what condition.)
Please list Non-Prescription Medications :
Are you allergic to any medications? :
List Medications :
Please circle YES or NO for any of the following Medical Services you have had for this Injury/Onset of problem.
X-Rays :
MRI :
CT-Scan :
Bone Scan :
EMG :
Others :
Orthopedist :
Neurologist :
Podiatrist :
Primary Care M.D :
Phisical Therapist :
Chiropractor :
Oral Surgeon :
Pain Clinic :
Emergency Room :
Other :
Please circle YES or NO if you have or have had any of the following:
Chest Pain/Angina :
Heart Disease :
Heart Attack :
Irregular Heart Beat :
Pacemaker :
High Blood Pressure :
Kidney Disease :
Bowl or bladder problems :
Liver Disease :
Stroke :
Blood Clots :
Vericose Veins :
Diabetes :
Asthma :
Breathing Difficulties :
Allergies :
Infectious Disease :
Cancer :
Hernia :
Arthritis :
Osteoporosis :
Gout :
Metal Pins or Implants :
Fractures :
Surgery :
Weight Loss :
Skin Abnormality :
Hearing Difficulty :
Vision Difficulty :
Seizures :
Weakness :
Nausea :
Headache :
Dizziness/Fainting :
Numbness Tingling :
Psychological Problems :
Sleeping Difficulty :
Pregnant :
Smoke or Tobacco use :
Other relevant medical history information :
If you would like to speak to a social worker about any aspect or your skilled physical therapy program please indicate.
What are your goals while in your physical therapy program?
Patient or Guardian Signature : Date :
Enter the numbers in the image :
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