Language
English (US)
Español
Patient History
Magnolia Physical Therapy & Wellness, Inc
Full Name :
*
First Name
Last Name
Birth Date :
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Primary Care Physician :
Referring Physician :
Emergency Contact :
*
First Name
Last Name
Emergency Contact Number :
-
Area Code
Phone Number
Back
Next
Recent Medical History
Reason for Therapy
I've experienced in the last six months :
elective surgery
emergency surgery
a fall without injury
a fall with injury
unintended weight loss
dizziness
difficulty sleeping
uncontrolled pain
an injury requiring medical attention
a new diagnosis
chronic (constant) pain
new onset of pain
Reason for therapy :
Goals for therapy :
Any additional information to share:
Back
Next
Past Medical History
Click all that apply :
High blood pressure
Cardiac disease
Lung disease
Diabetes (type I or II)
Blood disease or disorder
Autoimmune disease or disorder (Lupus, HIV+, etc)
Psychological illness (depression, ADD, etc)
Neurological condition (Parkinson's disease, stroke, etc)
Cancer
Osteoarthritis
Joint disease or condition (rheumatoid arthritis, gout, etc)
Amputation
Orthopedic surgery
Neurological surgery
Elective surgery
Heart attack
Cardiac surgery
Stroke or TIA
Congenital disability
Please explain in detail including dates if applicable:
Back
Next
Medications
Please list the medications you are currently taking.
Back
Next
Mobility
If Applicable
Please answer the following questions about mobility, if applicable :
No assistance needed
A little assistance
needed
A lot of assistance
needed
Completely dependent / unable
Ability to get in and out of bed PRIOR to current issue :
Ability to get in and out of bed at present :
Ability to move safely around your home PRIOR to current issue :
Ability to move safely around your home PRIOR to current issue :
Ability to navigate in the community PRIOR to current issue :
Ability to navigate in the community at present :
Back
Next
Signature of Agreement
I have truthfully answered all previous questions regarding my medical history.
Signature :
*
Clear
Name :
*
First Name
Last Name
Relationship to Patient :
*
Self
Spouse
Legal Guardian
Power of Attorney
Parent
Sibling
Son
Daughter
Paid Caregiver
Other
Date of Submission :
*
/
Month
/
Day
Year
Date Picker Icon
Submit
Should be Empty: