Patient Medical Information (Page 2 of 2) in pdf

Allergies:__________________________________________________________________________________________________

Are you Latex-Sensitive? Yes / No

Have you had any X-rays, CT scans, MRI, Bone Density scan, EMG, or Nerve Conduction study recently for this condition? Yes / No

If yes, when were the images taken and where?_____________________________________________________________________

Please list all current Medications (or provide list): __________________________________________________________________

____________________________________________________________________________________________________________

Past Surgical History and Hospitalizations (list all & dates): ____________________________________________________________

____________________________________________________________________________________________________________

Currently I Am Experiencing (circle all that apply):

Fatigue

Fever/Chills/Sweats

Nausea/Vomiting/Indigestion

Weight Gain/Loss (Unintentional)

Difficulty Maintaining Balance with Walking

Dizziness

Numbness or Tingling

Muscle Weakness

Headaches

Bowel and Bladder Changes

Shortness of Breath

Memory Loss

Fainting

Difficulty Swallowing

Difficulty with Word Retrieval

Medical History: Please Circle Each Condition That You Have Been Told You Have (or Had).

Cancer

Heart Disease

High Blood Pressure

Chest Pain/Angina

Circulatory Problems

Kidney Disease

Liver Disease

Lung Disease

Asthma

Diabetes

Stroke

Osteoporosis

Osteoarthritis

Rheumatoid Arthritis

Thyroid dysfunction

Bone/Joint Infection

Depression

Anemia

Fibromyalgia

Chemical dependency

Other:_____________________________________________________________________________________________________

Do you have a pacemaker? Yes / No

Are you currently pregnant, or think you may be pregnant? Yes / No

During the past month, have you often been bothered by feeling down, depressed, or hopeless? Yes / No

During the past month, have you often been bothered by having little interest or pleasure in doing things? Yes / No

Is this something with which you would like help (circle one)?

Yes

Yes, but not today

Castle Rehabilitation Services

Kailua

Kaneohe

640 Ulukahiki Street

46-001 Kamehameha Hwy., Suite 103

Kailua, Hawaii 96734

Kaneohe, Hawaii 96744

Tel: 808-263-5303

Tel: 808-263-5040

Castle Medical Center Kailua, Hawaii

PATIENT ID

PATIENT INFORMATION

Pg 2 of 2

Patient Medical Information Page 2

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