Hand and Upper Extremity Rehab, LLC



[pic]Hand and Upper Extremity Rehab, LLC

Patient Medical History Form

Patient Name: Date:

Occupation: Last date worked due to this Injury: Date returned to work after this injury:

Are you currently working? [ ]Full time [ ] Part-time [ ] Modified [ ] not working [ ] retired [ ] not working individual

Is an Attorney involved with this case: [ ] Yes [ ] No

Type of Surgery/Date(s) of Surgery:

Type of Injury/Date(s) of Injury:

MEDICAL HISTORY

1. Do you have any of the following medical illnesses/concerns? (Circle: yes or no)

Do you have a heart pace maker? Yes No Neck injury or surgery? Yes No

Have you had seizure or epilepsy? Yes No Knee injury or surgery? Yes No

Heart Problems or Angina? Yes No Shoulder injury or surgery? Yes No

High Blood Pressure? Yes No Back injury or surgery? Yes No

Is your blood pressure under control? Yes No Heart attacks or heart surgery? Yes No

Cancer? Yes No Blood clot or emboli? Yes No

Diabetes? Yes No Stroke or TIA? Yes No

Numbness (lack of sensation)? Yes No Asthma, Bronchitis, or emphysema? Yes No

Tingling: Yes No Do you smoke? Yes No

Are you pregnant: Yes No Bowel or bladder problems? Yes No

Any pins or metal? Yes No Anemia? Yes No

Location: Thyroid trouble or goiter? Yes No

Joint Replacement? Yes No Weight loss or lack of energy? Yes No

Allergies? Yes No Weakness? Yes No

Types: Dizziness or fainting? Yes No

Infectious diseases? Yes No Vision or hearing difficulty? Yes No

Types: Severe headaches? Yes No

Cancer/chemotherapy/radiation? Yes No Sleeping problems? Yes No

Arthritis or swollen joints? Yes No Other (Please write any medical illnesses/concerns not listed):

Osteoporosis? Yes No

Emotional or psychological problems? Yes No

PRESCRIPTION/MEDICATIONS

Are you currently taking any prescription or non-prescription medications? [_] Yes [_] No

Anti-inflammatory? List other medications:

Muscle Relaxers?

Pain medications?

PAIN: Please rate your pain (0 no pain – 10 extreme pain) with activity: currently:

GOALS: What are you expectations/goals while in this program?

MEDICAL PROFESSIONAL SERVICES

2. Do you have any of the following medical or rehabilitative services for this injury/surgery? (Circle: yes or no)

Occupational or Physical Therapy Yes No Chiropractor Yes No

EMG Yes No General MD Yes No

X-Rays Yes No Hand Surgeon Yes No

Emergency Room Care Yes No Neurologist Yes No

CT Scan Yes No Other:

MRI Yes No

3. Please provide any other information you feel is important:

Patient/Guardian Signature: Date: HUER Intake Initials:

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