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Past Medical History Form
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2020-04-02T21:01:20-04:00
Past Medical History
Patient Information
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Date
MM slash DD slash YYYY
Primary Care Provider
Specialist
What are we seeing you for?
Injury Date
MM slash DD slash YYYY
Surgery Date
MM slash DD slash YYYY
Height
Weight
Age
Select the phrase that best describes your current level of pain.
No pain
Slight pain
Mild pain
Moderate pain
Severe pain
Extreme pain
Worst pain imaginable
Location of Pain
When did the pain start?
Have you seen any other medical providers for this problem?
No
Yes
If yes:
Primary Care Provider
PT
OT
Chiropractor
Specialist
Other
Is this work related?
No
Yes
Motor Vehicle Accident?
No
Yes
Please describe the details of your accident if motor vehicle or work related.
Previous Physical Therapy?
No
Yes
Where?
Related Surgery
Date
MM slash DD slash YYYY
Related Surgery
Date
MM slash DD slash YYYY
Other Surgery
Date
MM slash DD slash YYYY
Have you fallen in the last 12 months?
No
Yes
If yes, did you injure yourself?
No
Yes
If yes, how did you fall?
Other Conditions
Please indicate if you have any of the following conditions:
Allergy
Anemia
Cancer
Arrhythmia
HIV/AIDS
Hypoglycemia
Incontinence
Kidney Disease
Hemophilia
Hepatitis
Hernia
High Blood Pressure
Recent Fractures
Recent Weight Loss
Rheumatoid Arthritis
Seizures
Osteoporosis
Pacemaker
Pregnancy
Claustrophobia
Diabetes
Dizziness
Fever
Gerd
Lung Problems
Skin Sensitivities
Headaches
Metal Implants
Stroke
Heart Attack/Failure
Nervous Disorder
Thrombophlebitis
Heart Disease
Open Wounds
Heart Murmur
Osteo-Arthritis
Have you ever had any serious illness not listed above?
No
Yes
If yes, please explain.
SIGNATURE OF PATIENT, PARENT OR GUARDIAN: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or to the patient’s) health. It is my responsibility to inform Allied Physical Therapy of any changes in my medical status.
Date
MM slash DD slash YYYY
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