HISTORIAL PERSONAL DE SALUD Forma

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HISTORIAL PERSONAL DE SALUD

Este formulario formara parte de su expediente medico. Al finalizar, firme la ultima pagina.

Nombre:
lHa visto a un cirujano ortopedico antes?
Historia medica pasada
Marque cualquier condici6n que tenga actualmente o haya tenido en el pasado:
lHas tenido cancer?
lPodrfa estar embarazada (solo mujeres en edad fertil)?
Antecedentes quirurgicos pasados
Marque cualquier procedimiento ortopedico o cirugfa que haya tenido en el pasado:
lTomas aspirina?
Queja actual/ Sintomas
lC6mo han cambiado sus sfntomas desde el inicio inicial?
lCual es la gravedad de su dolor (donde O = sin dolor y 10 = peor dolor)?
lHa tenido alguna imagen para el deterioro actual?
lActualmente experimenta alguno de los siguientes sfntomas?
lHa tenido terapia ffsica para este problema antes?
En el cuadro corporal, marque las areas donde siente sus sf ntomas:

Certifico que la informaci6n anterior es correcta a mi leal saber y entender. No responsabilizare a mi
terapeuta ni a ning(m miembro del personal de la oficina por errores u omisiones que pueda haber
cometido al completar este formulario.

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Find Us In Houston

We have 4 locations in Texas

MEMORIAL (NEW LOCATION)

9432 Katy Freeway, Suite 470 Houston, TX 77055

Opening Hours

  • MON-WED-FRI: 8:00am – 5:00pm
  • TUE & THR: 8:00am – 7:00pm
  • SATURDAY: 8:00am – 12:00pm
  • SUNDAY: Closed

EAST DOWNTOWN

2955 Gulf Freeway, Suite B Houston, TX 77003

Opening Hours

  • MONDAY: 10:00am – 7:00pm
  • TUE & THR: 9:00am – 5:00pm
  • WEDNESDAY: Closed
  • FRIDAY: 8:00am – 2:00pm
  • EVERY OTHER SAT: 8:00am – 12:00pm
  • SUNDAY: Closed

RIVER OAKS

3311 Richmond Ave, Suite 210 Houston, TX 77098

Opening Hours

  • MONDAY: 9:00am – 5:00pm
  • TUE & THR: 10:00am – 5:00pm
  • FRIDAY: 9:00am – 5:00pm
  • WED-SAT-SUN: Closed

SUGAR LAND

3527 Hwy 6 Ste 270 Sugar Land TX 77478

Opening Hours

  • MONDAY: 9:00am – 5:00pm
  • TUE & THR: 10:00am – 5:00pm
  • FRIDAY: 9:00am – 5:00pm
  • WED-SAT-SUN: Closed

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