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Contact us
(305) 904-6527
|
rehabconciergept@aol.com
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Patient Forms
MEDICAL HISTORY & SCREENING
Medical History and Screening Form
Name
*
Doctor/Other:
*
Marital Status:
*
Single
Married
Divorced
Widowed
Sex:
*
Male
Female
Please mark any that apply to your medical history:
High Blood Pressure
Asthma
Pacemaker
Glaucoma
Varicose Veins
Arthritis (Osteoarthritis)
Arthritis (Rhematoid)
Diabetes
Phlebitis (Inflammation of a Vein)
Dizziness or fainting spells
Epilepsy or Seizures
Stroke
High Cholesterol
Neuropathy
Any numbness or tingling in arms or legs
Any implants (breasts, surgical, joint replacement)
Depression
Constipation
Current Medication
Allergies
Anemia
Thyroid Problems
Bloodclots
Other
If you checked the implants/joint replacements above please describe:
Where is your pain located? Please describe in detail.
Please add descriptions like type of pain(burning, dull etc.) or levels of each.
Taking any bloodthinners?
Previous Surgeries?
Women only answer the following. Do you have:
Menstrual Period Problems?
Significant Childbirth - related problems?
Urinary leaking with cough, sneeze or laughing?
Pelvic Surgeries
Present Medical History
Please tell me your pain level on a scale of 1-10 (10 being the highest) for each area of pain.
Affected Area:
Check all that apply.
Radiating Pain
Numbness/Tingling
Sitting
Standing
Walking
At Rest
Symptoms worse in
A.M.
P.M.
How long have you had this problem?
Did you have any accidents/injuries in the last 3-6 months?
Have you seen any specialists besides your primary care physician for this problem?
Does anything make it better/worse?
What are your goals for physical therapy?
If you are human, leave this field blank.
Submit
Contact us
(305) 904-6527
|
rehabconciergept@aol.com
Home
Meet The Doctor
Treatments Offered
Pricing and Billing
Testimonials
Get Started
Patient Forms
