Patient Medical History Form
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Email *
First and Last Name *
Date of Birth *
Address *
Phone Number
Sex
Clear selection
Occupation
Emergency Contact- Name and Phone number
Height
Weight
Referring MD or Direct Access
How did you hear of us?
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Body part you are coming to PT for
Have you had surgery for this injury?
Clear selection
Have you had PT for this injury?
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Are you being treated by other healthcare professionals at this time, please list:
Please list any allergies:
Have you had any of the following for this injury?
Please list all medications (prescribed and over the counter) that you are currently taking: (Please include Name and Dose)
Do you have any of the following conditions?
List any surgeries you have had:
How many caffeinated drinks do you have per day?
How many packs of cigarettes do you have per day?
How many alcoholic beverages do you drink per week?
Please list three activities that you are limited with due to your injury:
Date *
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