Download Past Medical History - Bowden Physiotherapy

PAST MEDICAL HISTORY
DATE:
NAME:
DATE OF BIRTH
OCCUPATION:
LEISURE ACTIVITIES:
REASON FOR
CONSULTATION
Past Medical History
Metal implants (IUD, pins
Have you had Physiotherapy before, if so
where?
High Blood Pressure
and plates, etc, pacemaker)
Treatment for
Drug Allergies
cancer/TB
Heart or lung
Anticoagulants
problems
History of
Surgery
osteoporosis
Bladder or bowel
Diabetes
problems
Stroke or neurological
Epilepsy
problems
Bleeding disorders
Circulatory Disorders
Pregnant uterus
HIV/AIDS
Hepatitis A, B, C
Other