Revolve Physical Therapy

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Personal Health History

This form will be a part of your medical record. Upon completion, please sign the last page.

Have you seen an orthopedic surgeon before?
Past Medical History
Check any conditions that you currently have or have had in the past:
Have you had cancer?
Could you be pregnant (women in childbearing years only?)
Check any orthopedic procedures or surgeries that you have had in the past:
Do you take aspirin?

Current Complaint / Symptoms

How have your symptoms changed since intial onset?
What is the severity of your pain (where 0 = no pain and 10 = worst pain)?
Have you had any imaging for the current impairment?
Are you currently experiencing any of the following symptoms?
Have you had physical therapy for this problem before?
Please indicate the parts where you feel your symptoms:

I certify that the above information is correct to the best of my knowledge. I will not hold my therapist or any members of the office staff responsible for errors or omissions that I may have made in completing this form.

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