PERTINENT MEDICAL HISTORY FORM

CHECK OFF IF YOU HAVE OR ARE CURRENTLY EXPERIENCING THE FOLLOWING:

OTHER MEDICAL PROBLEMS   < PLEASE ELABORATE>

PLEASE LIST ANY SURGERIES IN THE PAST 15 YEARS:

PLEASE LIST ANY MEDICATIONS THAT YOU ARE PRESENTLY TAKING:

HAVE YOU RECEIVED PHYSICAL THERAPY FOR THIS PROBLEM? Y/N 
IF YES, WHEN?                                                   .

WHEN IS YOUR NEXT SCHEDULED DOCTORS APPOINTMENT?
                                                   

                                                   
(PATIENT'S SIGNATURE)

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