Patient Questionnaire Template - Upper Quarter And Cervical Spine Page 3
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4Current Medications — Check ALL that apply AND provide dosages — Attach a list if necessary
❑ Prescription________________________________________
❑ Not Currently Taking Any Medications
❑ Over The Counter________________
❑ Herbals___________________________________________
❑ Vitamins & Minerals______________
❑ Dietary & Nutritional Supplements ______________________
What are your Hobbies? _________________________________________________________________
What are your Physical Therapy Goals? ___________________________________________________
Current Weight: _________________
Current Height: __________________
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Parent category: Life