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Download Results Physical Therapy | physical fitness and therapy, gainesville
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Medical History Existing or Relevant Previous Conditions Allergies Anemia Anxiety Arthritis Asthma Autoimmune Disorder Cancer Cardiac Conditions Cardiac Pacemaker Chemical Dependency Circulation Problems Currently Pregnant Depression Diabetes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No Dizzy Spells Emphysema/Bronchitis Fibromyalgia Fractures Gallbladder Problems Headaches Hearing Impairment Hepatitis High Cholesterol High/Low Blood Pressure HIV/AIDS Incontinence Kidney Problems Metal Implants ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No MRSA Multiple Sclerosis Muscular Disease Osteoporosis Parkinsons Rheumatoid Arthritis Seizures Smoking Speech Problems Strokes Thyroid Disease Tuberculosis Vision Problems ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ Yes ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No ⃝ No Describe any other conditions If "Yes" to Any of the above, please explain and give approximate dates/Describe any other Conditions Fall History Injury as a result of a fall in the past year? ⃝ Yes ⃝ No Two or more falls in the last year? ⃝ Yes ⃝ No Patient is at risk for falls? ⃝ Yes ⃝ No Surgical History Body Region: ______________________ Surgery Type: ________________________ Date: ______________, _______, __________ Body Region: ______________________ Surgery Type: ________________________ Date: ______________, _______, __________ Body Region: ______________________ Surgery Type: ________________________ Date: ______________, _______, __________ Body Region: ______________________ Surgery Type: ________________________ Date: ______________, _______, __________ Current Medications Drug: _______________ Dosage: _______ Frequency: ___________ Route: ___________ Reason Taking: ______________________ Drug: _______________ Dosage: _______ Frequency: ___________ Route: ___________ Reason Taking: ______________________ Drug: _______________ Dosage: _______ Frequency: ___________ Route: ___________ Reason Taking: ______________________ Drug: _______________ Dosage: _______ Frequency: ___________ Route: ___________ Reason Taking: ______________________ Currently not taking any medications 11/19/13
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