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Patient History
Magnolia Physical Therapy & Wellness, Inc
Full Name :
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First Name
Last Name
Birth Date :
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Primary Care Physician :
Referring Physician :
Emergency Contact :
*
First Name
Last Name
Emergency Contact Number :
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Area Code
Phone Number
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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
Other
Reason for therapy :
Goals for therapy :
Any additional information to share:
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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
Other
Please explain in detail including dates if applicable:
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Medications
Please list the medications you are currently taking.
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Mobility
If Applicable
Please answer the following questions about mobility, if applicable :
Rows
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 at present :
Ability to navigate in the community PRIOR to current issue :
Ability to navigate in the community at present :
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Signature of Agreement
I have truthfully answered all previous questions regarding my medical history.
Signature :
*
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 :
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