Momentum Physical Therapy Medical History

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Momentum Physical Therapy
PAST MEDICAL HISTORY FORM
Patient Name:
Date:
Are you presently working?
Yes
No
Date of next physician’s visit:
/
/
Date of injury / onset:
/
/
Have you ever had these symptoms before?
Yes
No
Check which apply to your symptoms:
Work related injury
Recurrence of previous injury
Motor vehicle accident
Injury related to lifting
Injury related to falling
Cause unknown
Athletic / recreational injury
Other: _________________
Have you had a related surgery?
Yes
No
Do you have, or have you had any of the following?
Yes
No
Yes
No
Diabetes
Allergies to Aspirin
Chest Pain / Angina
Allergies to Heat
High Blood Pressure
Allergies / Poor tolerance to Cold
Heart Disease
Other Allergies
Heart Attack
Hernia
Heart Palpitations
Seizures
Pacemaker
Metal Implants
Headaches
Dizziness / Fainting
Kidney Problems
Recent Fractures
Are you pregnant?
Surgeries
Cancer
Skin Abnormalities
Osteoporosis
Sexual Dysfunction
Bowel / Bladder Abnormalities
Nausea / Vomiting
Urine Leakage
Ringing in your ears
Asthma / Breathing Difficulties
Rheumatoid Arthritis
Liver / Gallbladder Problems
Special Diet Guidelines
Smoking
Hypoglycemia
Stroke/CVA
Other:_______________________
If yes on any of the above, please briefly explain and give approximated date:
Is there any other information regarding your past medical history that we should know about?
Are you presently taking Medication?
Yes
No
If yes, please list what medications and for what condition:
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