Patient Medical Information Form
This form is beneficial for you to fill out entirely. This form helps our staff with any questions we may receive from
insurance or the therapists who are treating you/your child. Please fill out and add additional information as necessary. Information given in this form is confidential.
Guardian/Legal Representative Name
Relationship to Patient
Primary Physician Phone Number
Other specialist(s) name and number we can contact
Please provide the reason/diagnosis and date for the hospitalization/surgery
Please list any other significant medical issues
Please list any medications and dosage you/the child is currently taking (include supplements)
Please list any known drug or food allergies and the nature of the reaction (rash, swelling, etc.)
Please check if you/your child has/had the following illnesses
Hypertension (high blood pressure)
Thyroid disease/Lupus/Autoimmune Disease
Other genetic conditions/diseases
None of the above
Please provide detailed information about the illnesses selected above.
Any other information you would like us to know about you/your child
Send me a copy of my responses.
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