MEDICAL HISTORY Name Emergency Contact Ph Ph Present Condition/Previous Care 1. Have you had any previous physical therapy or other treatments this year such as chiropractic, acupuncture, etc? If yes, explain 2. Please list any prescription or non-prescription medication that you currently take Diagnostic tests Check if you have had: 1.X-rays 2.MRI 3.CT Scan 4.EMG 5.Stress Test 6.Blood Test 7.Doppler Ultrasound 8.Biopsy Describe your general health 1.Excellent 2.Good 3.Fair 4.Poor Medical/Surgical History Please check if you have ever had any listed 1.Arthritis 2.High blood sugar 3.Infectious disease 4.Circulation/vascular problems 5.Heart Problems 6.Parkinson’s 7.Developmental problems 8.Diabetes 9.Cancer 10.Blood disorder 11.Muscular Dystrophy 12.Depression 13.Thyroid problem 14.Osteoporosis 16.Multiple Sclerosis 17.Skin diseases 18.Lung problems 19.Stroke 20.Broken bones/Fractures 21.Low blood sugar 22.Kidney problems 23.Ulcers/Stomach problems 24.High blood pressure 25.Seizures/Epilepsy 26.Allergies 27.Other Within the past year, have you had any of the following symptoms?(Check all that apply) 1.Chest pain 2.Joint pain/Swelling 3.Fever/Chills/Sweats 4.Dizziness/Blackouts 5.Nausea/Vomiting 6.Difficulty swallowing 7.Difficulty walking 8.Urinary problems 9.Shortness of breath 10.Loss of Appetite 11.Vision problems 12.Loss of balance 13.Weight loss/gain 14.Cough/hoarseness 15.Difficulty sleeping 16.Hearing problems 17.Weakness in arms/legs 18.Bowel problems 19.Heart palpitations 20.Pain at night 21.Headaches 22.Coordination problems 23.Other By signing below, you state that all of the information is true and current to date. Patient’s Signature Spouse/Guardian Signature (if patient unable) Date Date Download 347 Elisa Drive | Englewood Cliffs, NJ 07632 201-661-0811
347 Elisa Drive | Englewood Cliffs, NJ 07632
201-661-0811