Ultimate Physical Therapy Patient Information Form Page 2

ADVERTISEMENT

PATIENT MEDICAL HISTORY
Primary Care Physician: ______________________________________________
Address: ___________________________________Phone #_______________________________
Treating Physician: ___________________________________________
Emergency Contact Name and Phone #_______________________________________________
Have you had Surgery for this Injury? YES / NO
Type of Surgery: _________________________________________________________
Have you or a Family member ever been treated at Ultimate Physical Therapy?
☐ Y ☐ N

Patient’s Name:_____________________________________________________
Have you had physical therapy for this condition? ☐Y ☐N If yes, for how long? ______________
Have you had physical therapy this year? If so, how many visits?___________________________
Are You Currently Taking Any Prescription or Non-Prescription Medications:
Yes / No (Please List):___________________________________________________________
_____________________________________________________________________________
Have you had any of the following medical or rehabilitative services for this injury/episode?
Chiropractor / Massage Therapy / Occupational Therapy / Physical Therapy
Emergency Room Care / General Practitioner / MRI / Neurologist / Orthopedist
Do you have or have you had any of the following?
Anemia / Diabetes/ Gout / Hernia /Allergies / Osteoporosis / Stroke /Blood Clot / Emboli
Epilepsy / Seizures / Varicose Veins / Joint Replacement/ Asthma, Bronchitis, or Emphysema
Shortness of Breath / Chest Pain / Coronary Heart Disease Cancer / Chemotherapy / Radiation
Emotional or Psychological Problems / Bowel or Bladder Problems
Severe or Frequent Headaches / Vision or Hearing Difficulties
Do you have a Pacemaker? _____Any Pins or Metal Implants? _________
Do you have any Infectious Diseases?__________ HIV?___________
Numbness or Tingling?___________Are You Pregnant?_______Do You Smoke?___________
List any other information that would assist us in your care?
________________________________________________________________________________
________________________________________________________________________________
Based upon your awareness, what are your expectations/goals while in this program?
__________________________________________________________________________
__________________________________________________________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Physical Therapy Patient Attestation Form Physical Therapy Patient Attestation Form Medical
Patient Therapy Patient Intake Form Patient Therapy Patient Intake Form Business
Physical Therapy Initial Evaluation Form Physical Therapy Initial Evaluation Form Medical
Patient Information Form For Patients Under 18 Years Of Age Form Patient Information Form For Patients Under 18 Years Of Age Form Medical
Patient Information Form With Emergency Contact And Health Information Patient Information Form With Emergency Contact And Health Information Medical
Patient Information Form Patient Information Form Medical
Patient Information Form Patient Information Form Medical
Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Patient Information Form - Green Valley Ranch Medical Clinic & Urgent Care Medical
Patient Information Form Patient Information Form Medical
Patient Information Form Patient Information Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 5