Medical History

Name(Required)

First Last

Date of next Dr Appt

Describe the history of your current accident, injury, illness or condition(Required)

Onset Date(Required)

Special concerns, questions or expectations:

Have you fallen in the past year?(Required)

Yes

No

How Many Times?(Required)

Did you sustain an injury(Required)

Have you had any physical therapy during the current calendar year?(Required)

Yes

No

For what?(Required)

When?(Required)

Where?(Required)

List all medications you are currently taking

List all recent diagnostic studies (CAT Scan, MRI, X-ray, etc) When and Where:

Do you have any metal anywhere in your body, other than teeth?(Required)

Yes

No

Please Describe(Required)

List all surgeries and dates

Please check each of the following that applies to you

Signature(Required)

Date(Required)