Patient Medical History

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Patient Medical History

Referring Physician: ________________________________ Family Physician: ________________________________

Date of First Doctor Visit for this Injury: ____________ Is an attorney involved in this case? Yes No

Number of surgeries you have had for this injury: 0   1    2    3   Other  __

Type of surgery: _________________________________ Date:________   Took place in: Hospital   Surgery Center

Are you currently taking any prescription or non-prescription medication? Yes    No

List Medications: Anti-inflammatory _____________________ Muscle Relaxers _____________________ Pain Medication _____________________

Have you had any of the following Medical or Rehabilitative Services for this injury/episode?

  Yes No   Yes No
Chiropractor _____ _____ CT Scan _____ _____
EMG/NCV _____ _____ General Practitioner _____ _____
Massage Therapy _____ _____ MRI _____ _____
Occupational Therapy _____ _____ Orthopedist _____ _____
Myelogram _____ _____ Neurologist _____ _____
Physical Therapy _____ _____ Physiatrist _____ _____
Emergency Room _____ _____ X-Rays _____ _____
Have or ever had any of the following? Yes No   Yes No
Asthma, Bronchitis or Emphysema _____ _____ Severe or Frequent Headaches _____ _____
Shortness of Breath/Chest Pain _____ _____ Vision or Hearing Difficulties _____ _____
Heart attack/Coronary/Angina _____ _____ Numbness or Tingling _____ _____
Do you have a Pacemaker? _____ _____ Dizziness or Fainting _____ _____
High Blood Pressure _____ _____ Weakness _____ _____
      Weight Loss/Energy Loss _____ _____
Stroke/TIA _____ _____ Hernia _____ _____
Blood Clot/Emboli _____ _____ Varicose Veins _____ _____
Epilepsy/Seizures _____ _____ Allergies _____ _____
Thyroid Trouble/Goiter _____ _____ Any Pins or Metal Implants _____ _____
Anemia _____ _____ Joint Replacement _____ _____
Infectious Diseases _____ _____ Neck Injury/Surgery _____ _____
Diabetes _____ _____ Shoulder Injury/Surgery _____ _____
Cancer or Chemotherapy _____ _____ Elbow/Hand Injury/Surgery _____ _____
Arthritis/Swollen Joints/Gout _____ _____ Back Injury/Surgery _____ _____
Osteoporosis _____ _____ Hip/Knee Injury/Surgery _____ _____
Parkinsons _____ _____ Leg/Ankle/Foot Injury/Surgery _____ _____
Emotional/Psychological Problems _____ _____ Are you pregnant? _____ _____
Bowel or Bladder Problems _____ _____ Do you smoke? _____ _____

List any other information that would assist us in your care:

___________________________________________________________________________________________________________________________

What are your expectations/goals while in this program?

___________________________________________________________________________________________________________________________

 

Signature: ________________________________ Parent/Guardian Signature: ________________________________ Date: ____________________