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Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Menu
Home
About
About Us
Our Staff
Service Area
Our Services
Redcord
DRY NEEDLING
WELLNESS AND RECOVERY
More
Gallery
Contact Us
faq
Blog
Back Pain
Patient Forms
Call Us Now
Medical History Form
Filling out paperwork prior to your visit means your therapist can spend more time assessing and treating you.
Please click on the appropriate box to submit your form. Thank you!
Patient History
First Name
Last Name
Date
Primary Care Physician :
Referring Physician
Emergency Contact
First Name
Last Name
Emergency Contact Number
Area Code
Phone Number
Recent Medical History
Reason for Therapy
I've experienced in the last six months
elective surgery
a fall without injury
unintended weight loss
difficulty sleeping
an injury requiring medical attention
chronic (constant) pain
emergency surgery
a fall with injury
dizziness
uncontrolled pain
a new diagnosis
new onset of pain
If you have other experienced in the last six month
Reason for therapy
Goals for therapy
Any additional information to shar
Past Medical History
Click all that apply
High blood pressure
Cardiac disease
Lung disease
Diabetes (type I or II)
Blood disease or disorder
Autoimmune disease or disorder (Lupus, HIV+, etc)
Psychological illness (depression, ADD, etc)
Neurological condition (Parkinson's disease, stroke, etc)
Cancer
Osteoarthritis
Joint disease or condition (rheumatoid arthritis, gout, etc)
Amputation
Orthopedic surgery
Neurological surgery
Elective surgery
Heart attack
Cardiac surgery
Stroke or TIA
Congenital disability
Please explain in detail including dates if applicable
Medications
Please list the medications you are currently taking.
Mobility
If Applicable
Ability to get in and out of bed PRIOR to current issue
No assistance needed
A little assistance needed
A lot of assistance needed
Completely dependent / unable
Ability to move safely around your home PRIOR to current issue
No assistance needed
A little assistance needed
A lot of assistance needed
Completely dependent / unable
Ability to get in and out of bed at present
No assistance needed
A little assistance needed
A lot of assistance needed
Completely dependent / unable
Ability to move safely around your home at present
No assistance needed
A little assistance needed
A lot of assistance needed
Completely dependent / unable
Ability to navigate in the community PRIOR to current issue
No assistance needed
A little assistance needed
A lot of assistance needed
Completely dependent / unable
Ability to navigate in the community at present
No assistance needed
A little assistance needed
A lot of assistance needed
Completely dependent / unable
Signature of Agreement
I have truthfully answered all previous questions regarding my medical history.
Signature
First Name
Last Name
Relationship to Patient
Self
Spouse
Legal Guardian
Power of Attorney
Parent
Sibling
Son
Daughter
Paid Caregiver
Other
Date of Submission
Submit
