Download Health Statement pdf. - Myotherapy Institute

Myotherapy Institute 4001 Pioneer Woods Drive, Lincoln, NE 68516 Fax: 402-­‐421-­‐6736 Telephone: 402-­‐421-­‐7410 [email protected] Health Statement This form is to be completed and submitted by the physician’s office. Physical Patient Name ________________________________________________________Date______________________ M/F __________ Ht.__________Wt.__________B.P.__________Pulse__________ Hearing Deficit _____________________________________________Visual Deficit _________________________ Indicate and explain any abnormalities: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ To the best of your knowledge is the patient free of communicable disease today? Yes No Laboratory CBC ___________________________ Indicateabnormalities___________________________________________________________________________ PPD Date ____________ Negative ____________ Positive ____________ Follow up ________________________ Tuberculosis Negative Positive __________________________________________________________________ Immunizations Month/Day/Year Hepatitis B (optional) Tetanus ______ /______ /______ ______ /______ /______ Rubella Rubeola ______ /______ /______ ______ /______ /______ ______ /______ /______ Polio last date Varicella ______ /______ /______ ______ /______ /______ ______ /______ /______ ______ /______ /______ Mumps ______ /______ /______ Current Medications _____________________________________________________________________________________________
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_____________________________________________________________________________________________ General If this patient is currently under medical supervision. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Print Physician Name ____________________________________________________ Telephone _____________ Address ______________________________________________________________________________________ Physician’s Signature ________________________________________ Examination Date _____________________