Medical History Form/Consent to Care Medical History Please fill out the form below to submit your history and consent to care..Full Legal NameI prefer to be calledDate of BirthEmailPhone/MobilePast Medical HistoryMark any of the following that you have been diagnosed with: Heart problems Respiratory problems Neurological disorder Eating disorder Depression Psychological disorder Rheumatoid arthritis Cancer Renal disease Blood disorder Anemia Epilepsy/Seizures Asthma Diabetes High blood pressure Infectious disease None of the abovePlease list any medications you are currently takingPlease list any known allergies that you may haveDuring the past month have you often been bothered by feeling down, depressed, or hopeless? Yes NoDuring the last month have you often been bothered by little interest or pleasure in doing things? Yes NoPlease list any other previous medical/injury history of which you think we should be awareCurrent InjuryDate of InjuryLocation of InjuryHow did the injury occur?Did you have surgery for this injury? Yes NoWhat was the date of surgery?What was the surgical procedure performed?Please describe your current symptoms/issueWhat is your goal from physical therapy?Since the onset of your symptoms have you had any of the following? Unexplained weight change Dizziness or fainting Fever or chills Intractable night pain/sweats Numbness Weakness Malaise (overall "sick" feeling) None of the aboveWhat visit frequency are you expecting? Just a one time visit for some quick education on diagnosis and self-management Extensive home program with occasional check-in to test and progress (usually once every week or two) I prefer to do the majority of my rehabilitation under direct supervision (usually 2-3 times per week) I have no expectations regarding frequencyAnything else you think we should know?Attestation I, the undersigned, attest that the information provided on this form is accurate to the best of my knowledge as of this date. If any information provided on this form changes, I understand that it is my responsibility to provide that updated information to PTSC Group, Inc. before any additional physical therapy sessions are provided.Consent for Care and Treatment I, the undersigned, do hereby agree and give my consent for PTSC Group, Inc. or its contracted agents to furnish medical care and treatment considered necessary and proper in diagnosing or treatment of my physical condition.Statement of Financial Responsibility I, the undersigned, understand that I am responsible for the entire bill when the services are rendered unless other arrangements have been made.Signature Sign Here Submit Form
