Patient Forms
Patient Forms
Patient Forms
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REHABILITATION SERVICES MEDICAL HISTORY<br />
Name<br />
Date<br />
Do you have an Advanced Directive<br />
Do you have allergies to medications<br />
Describe reaction<br />
Yes<br />
None<br />
No<br />
Allergy<br />
Please list all medications you are currently taking (including over the counter or supply a copy of your med list):<br />
Current or Past Medical History (please mark all that apply)<br />
Difficulty swallowing Stroke<br />
Arthritis<br />
Diabetes<br />
High blood pressure Blood Clots<br />
Anemia<br />
Supplemental 02 use<br />
Pacemaker Shortness of breath Cancer<br />
Frequent falls<br />
Dizziness<br />
Heart problems/angina<br />
Urinary Incontinence Osteoporosis<br />
Epilepsy/seizures<br />
History of Current Problems that you are seeking therapy services for:<br />
Onset date for your symptoms/problems<br />
How did it happen<br />
Have you previously had a similar problem<br />
List any diagnostic studies you have had for this problem<br />
Have you ever had therapy for this condition<br />
Did it help<br />
Does your current condition limit you in carrying out your job or household duties<br />
Do you have any other orthopedic problems<br />
List any previous surgeries<br />
What are your goals for therapy<br />
Thanks you for taking the time to fill out this form as completely as possible. It will save us on treatment<br />
time during your first visit and will help in assessing your condition and guiding your treatment plan.<br />
MARSHALL MEDICAL CENTER<br />
REHABILITATION SERVICES<br />
MEDICAL HISTORY<br />
*0597636* Page 1 of 2 (3/13)<br />
MedicalHistoryp1
REHABILITATION SERVICES MEDICAL HISTORY-page 2<br />
Draw in areas of pain on body diagrams using appropriate symbols.<br />
Severe Pain<br />
Moderate Pain<br />
Dull Ache<br />
Radiating Pain<br />
Numbness/Tingling<br />
*******<br />
0000000<br />
∩∩∩∩∩<br />
↑↓↑↓↑↓↑↓<br />
XXXXXXX<br />
Reviewed by _____________________________________________ Date _______________ Time ________________<br />
Signature / Title<br />
MARSHALL MEDICAL CENTER<br />
REHABILITATION SERVICES<br />
MEDICAL HISTORY<br />
*0597636* Page 2 of 2 (3/13)<br />
MedicalHistoryp2
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