Superior Physical Therapy Past Medical History Form
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1Superior Physical Therapy Past Medical History Form
It is very important that you take the time to fill out this sheet as completely as possible.
We strive to provide you with superior care. Understanding your past medical history
is a big part of this. So please take the time to fill this form out as accurate as possible.
Patient Name
___________________________
DOB:
_________________
Please list any allergies (including laytex, chemical or food)
______________________________
_______________________________________________________________________________
Name of Medication:
Dosage
What it is for:
_____________________ _________
___________________________
_____________________ _________
___________________________
_____________________ _________
___________________________
_____________________ _________
___________________________
_____________________ _________
___________________________
_____________________ _________
___________________________
_____________________ _________
___________________________
_____________________ _________
___________________________
any other medications please list on back of this form
Previous Surgeries or Hospitalization and date
____________________________
_____________________________________________
____________________________
_____________________________________________
____________________________
_____________________________________________
Any other history:
_____
High blood pressure
_____
Stroke
_____
Pregnancy
_____
Heart Disease
_____
Asthma
_____
Epilepsy
_____
Cardic Pacemaker
_____
Cancer
_____
Tuberculosis
_____
Hepatitis
_____
Diabetes
_____
HIV/Aids
other:
______________________________________________________________________
Have you recently experienced any of the following?
_____
weight loss/gain
_____
weakness/falls
_____
fever/chills/sweats
_____
nausea/vomiting
_____
fatigue
_____
numbness/tingling
Treatment received for current condition:
_______________________________________
_______________________________________________________________________________
Do you have a do not resuscitate order?
yes
no
Patient Signature:
Date:
______________________________
______________________
The above information is true to the best of my knowledge:
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Parent category: Medical