Patient Information Form Page 2

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Please check if you have ever had:
Do you take prescription medications?
Arthritis
Yes
No
Broken bones, fractures
If yes, please list __________________________________
Osteoporosis
_________________________________________________
Blood disorders
_________________________________________________
Circulation/vascular disorder
_________________________________________________
Heart problems
_________________________________________________
Pacemaker
Allergies? ___________________________________
High blood pressure
____________________________________________
Lung problems
Do you take any non-prescription medication?
Yes
No
Stroke
Advil/Aleve
Diabetes/high blood sugar
Ibuprofen/ Naproxen
Low blood sugar/hypoglycemia
Aspirin
Head injury
Tylenol
Multiple sclerosis
Other _________________
Muscular dystrophy
Are you a smoker?
Yes
No
Parkinson’s disease
Within the past year, have you had any of the following
Seizures/ epilepsy
tests?
Developmental/growth disorders
Arthroscopy
Thyroid problems
Biopsy
Cancer
TYPE _________________
Blood tests
Infectious disease
Bone scan
Kidney problems
CT scan
Ulcers/ stomach problems
Doppler ultrasound
Skin diseases
Echocardiogram
Depression
EMG
Other__________________
EKG
Have you ever had surgery?
MRI
Yes
No
Myelogram
Surgery Date AND Type
Nerve conduction velocity
______________________________
Pulmonary function
Stress test
______________________________
X-rays
Other: __________________
______________________________
I certify that all of the information on this intake form is true and correct to the best of my knowledge
and that I understand the policies of FirstCare Physical Therapy. I give my consent to receive any and
all treatment that is rendered at FirstCare Physical Therapy. I am responsible for notifying the Center
of any changes in my health or billing information. I give consent for the Center to bill my insurance
company and for assignment of direct payment to the Center by my insurance company. The Center will
make every effort to collect payment from my insurance company, however I understand that
regardless of my account status, I am ultimately responsible for all charges incurred for professional
services rendered at FirstCare Physical Therapy to the extent that the law allows.
Signature________________________________________Date___________________
I authorize the release of any all information in your possession, custody, and control, including x-rays,
medical records, and emergency room records and test reports. The undersigned expressly authorizes
the release of my complete hospital/physician’s office chart to FirstCare Physical Therapy. I also give
consent for the Center to release their records, within the guidelines of the law, as necessary to my
physician, insurance company, rehab nurse/case manager or attorney.
Signature________________________________________Date___________________

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