Patient Information #2

Name*

First Last

Age*

3. Are you now under the care of physician therapist or physiatrist?*

Please list the dates of:

Hospitalizations*

Surgeries*

Height: (cm)

Weight: (kg)*

Medications*

PAST MEDICAL HISTORY & REVIEW OF SYSTEMS Please check if you have ever had or presently have any of the following:*

31.History of fall. How many episodes did you have in past 12 month*

Patient Signature*

Date*

For Office Use Only:

BMI

Blood Pressure*

Heart Rate*