Milestone Therapy Patient Medical History

Patient Medical History

v2.0
Patient Information
Patient's Name*

First NameMiddle NameLast Name
Patient's Email*
example@example.com
Past Medical History
Please check any condition you have been medically diagnosed to have

High blood pressureLow blood pressureHeart conditionPacemakerHigh CholesterolStrokeSeizuresNeurological ConditionAids/HIVCirculation disordersBreathing disorders (specify below)Allergies - FoodAllergies - MediationAllergies - EnvironmentAllergies - Latex or AdhesivesTuberculosis (treatment or exposure)Drug/Alcohol AddictionHepatitisFalls or Loss of BalanceDiabetesCancer (specify below)Unexplained Weight LossThyroid ProblemsDepressionDizzinessAre you or could you be pregnant?Other (specify)
If you need to specify conditions, please do so here.
List ALL your Medications here
List Your Surgeries here
Have you received home health?

YesNo
Have you been hospitalized in the last 12 months?

YesNo
Have you missed work because of this injury?

YesNo
When did your problem begin?
Have you had therapy before?

YesNo
If you have had therapy before, when?
What activities did you participate in prior to injury?
What is your therapy goal?
I would like to be contacted in the future about clinic educational and promotional events:

NoYes. Please provide us with your email address below
Email
example@example.com
Mark the areas on the diagram where you experience symptoms
On the diagram below, please mark the places where you experience symptoms:
- Pain = X
- Numbness = O
- Stabbing/Sharp = S
- Pins and Needles = N
Annotate Image
Please rate your pain between 0-10*

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst Pain
Reference form: 35998583 New 10/11
Should be Empty:

Patient Medical History

Patient Information

Past Medical History

Mark the areas on the diagram where you experience symptoms