Mobile Orthopaedics & Rehabilitation Physical Therapy, Inc.

9010 Hornbaker Rd., Ste. 1019384 Forestwood Lane, Ste. D

Manassas, VA 20109Manassas, VA 20110

Office: (703) 361-9677 Office: (703) 361-9677

Fax: (703) 361-9678Fax: (703) 361-9678

PAST MEDICAL HISTORY FORM

Patient Name: ______Date: ______

Are you presently working? ______Yes______No

Date of next physician’s visit: ______

1.Date of injury onset: ______

2.Mechanism of injury: ______

3.Have you ever experienced these symptoms before? Yes (please explain)  No

______

4.Check all which apply to current condition:

 motor vehicle accident  work related injury  injury related to lifting

 injury related to falling  athletic/recreational injury  recurrence of previous injury

 cause unknown  other: ______

5. Have you had a related injury?  Yes No

6. If female, are you pregnant?  Yes No

Do you have, or have you had any of the following:

YES NOYES NO

Diabetes /  /  / Hypoglycemia /  
Chest pain/Angina /  /  / Osteoarthritis /  
High Blood Pressure /  /  / Osteoporosis /  
Heart Disease /  /  / Hernia /  
Heart attack /  /  / Seizures /  
Heart Palpitations /  /  / Metal Implants /  
Pacemaker/Defibullator /  /  / Fractures /  
Headaches /  /  / Dizziness/Fainting /  
Kidney problems /  /  / Surgeries /  
Cancer /  /  / Skin Abnormalities /  
Stroke /  /  / Nausea/Vomiting /  
Bowel/Bladder Abnormalities /  /  / Ringing in the ears /  
Urine Leakage /  /  / Rheumatoid Arthritis /  
Asthma/Breathing Difficulties /  /  / Smoking: How long /  
Liver/Gallbladder Problems /  /  / Other /  

If you answered Yes to any of the items above, please briefly explain and give the date. Include any other pertinent information regarding your past medical history.

7. Do you have any allergies?  Yes No

If yes, please list your allergies: ______

8. Are you presently taking any medication?  Yes No

If yes, please list what medications and for what condition:

______

  1. Do you participate in any sports, exercise programs or activities on a regular basis? Yes No. If yes, please list: ______
  1. Please indicate below where your symptoms are located.

Key: Numbness ======

Pins & Needles 0000000

Burning Pain xxxxxxx

Stabbing Pain /////////////

11. If you are having pain, please rate the intensity of your pain on a scale of 0-10, with 0 being No pain and 10 being the worst pain possible: ______

CONSENT TO TREATMENT

I understand that I have been referred for rehabilitative treatment and care to Mobile Orthopaedics & Rehabilitation Physical Therapy, Inc. clinic. Mobile Orthopaedics & Rehabilitation Physical Therapy, Inc has described for me my individual treatment plan. I understand that I have the right to ask and have any questions answered prior to receiving any treatment including any risks or alternatives to the treatment plan that has been prescribed for me. By signing this agreement, I consent to have Mobile Orthopaedic & Rehabilitation Physical Therapy, Inc. provide treatment and care as prescribed by my physician and /or recommended by my physical therapist.

Signature______Date______

Witness______

Relationship to Patient______

(Self, parent, guardian, spouse, etc.)