Momentum Physical Therapy Medical History Page 2

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In the rare instance of an emergency, whom should we contact?
Name:
Phone Number:
Please indicate below where your symptoms are located.
KEY:
Numbness ========
Pins & Needles
ooooooo
Burning Pain xxxxxxxx
Stabbing Pain
/ / / / / / / /
If you are having pain, please rate the intensity of your pain on a scale of 0 to 10, with 0 being no pain and 10 being
the worst pain possible: ___________________.
Patient’s Signature
Date
Signature of Guardian if patient is a minor
Date
/
/
Therapist Signature
Date
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