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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