Balance & Mobility Therapy Medical History Form
Download a blank fillable Balance & Mobility Therapy Medical History Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Balance & Mobility Therapy Medical History Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Balance & Mobility Therapy
MEDICAL HISTORY FORM
Please fill this form out, print, and turn in at your first appointment.
Name:_____________________________________________________________ Age:_____________________________
Area of Symptoms:_____________________________________________________________________________________
Date Symptoms Started:_________________________________________________________________________________
Please take a moment to complete the questions below. Depending on your answers, we may modify treatment procedures
for their effectiveness and you safety.
Any known results of recent X-rays or tests:_________________________________________________________________
Chronic Conditions:
Yes
No
if yes, please list: _____________________________________
Medications:
Yes
No
if yes, please list:_________________________________________________
Allergies:
Yes
No
if yes, please list:_________________________________________________
Latex Sensitive:
Yes
No
List surgeries and dates:_________________________________________________________________________________
Do you or have you had any of the following:
Cancer
Yes
No
High Blood Pressure
Yes
No
Diabetes
Yes
No
Metal Implants
Yes
No
Epilepsy/Seizures
Yes
No
Respiratory Problems
Yes
No
Heart Disease
Yes
No
Hepatitis
Yes
No
Tuberculosis
Yes
No
Are you pregnant?
Yes
No
1. How would you rate your ability to perform your routine daily activities?
(no problems)
(unable to perform)
0
1
2
3
4
5
6
7
8
9
10
2. How would you rate your ability to perform the activities associated with your job?
(no problems)
(unable to perform)
0
1
2
3
4
5
6
7
8
9
10
3. How many days since your current injury?
0-30 days
31-90 days
91+ days
How did you select our service?
Doctor recommendation
Previous patient
Ad in phone book
Insurance provider directory
Family/Friend recommended
Internet Search
Radio
Newspaper
Other_______________
Please draw your pain on the body to the right using the
following symbols: Please do so after you print this
form out.
///
Stabbing Pain
xxx
Burning Pain
ooo
Pins and Needles
= = =
Numbness
_______________________________________________________________ ____________________________________
Patient Name
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical