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Home
About
Biomechanix History
Our Team
Facility
Careers
Education
Services
Sports Injuries
Neurological Conditions
Custom Foot Orthotics
Pre and Post-Surgical Conditions
Amputees
Dry Needling and Vertigo
All Orthopedic and Spine Injuries
Pediatrics
Injury Prevention and Ergonomic Education
Patient Center
Getting Started
Accepted Insurance
Forms
Contact Us
Medical History
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*
" indicates required fields
Patient Name
*
Date
MM slash DD slash YYYY
Are you currently taking any medications?
*
Yes
No
Please List
*
Are you currently receiving home health care?
*
Yes
No
Condition
*
Asthma
Diabetes
High Blood Pressure
Heart Problems
Lung Problems
Cancer
Seizures
Arthritis
Stroke/CVA
Condition
*
Fracture/Broken Bones
Neuromuscular
Dizziness/Blackouts
Headaches/Migraine
Blood Clots/ Vascular
Bladder/Bowel Disorder
Pregnancies #
Other
Diagnostics
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Orthopedic Surgery
Joint Replacements
Spinal Surgery
Heart Surgery
Fracture Reductions
Joint Manipulations
Other Surgeries
Date
*
MM slash DD slash YYYY
Please Describe
*
Current Limitations/Restrictions
*
Surgical
*
X-Rays
CT Scans
MRI
EMG Nerve Studies
Injections
Date
*
MM slash DD slash YYYY
Results
*
Pain/Symptoms
*
1. Please rate your current pain level by marking a number on the scale: (0 To 10)
*
No Pain
ER Visit
Number
*
Please enter a number from
0
to
10
.
2. On the BODY DIAGRAM► please describe your symptoms using the Following symbols: (X) Sharp (=) Numb/Tingling (#) Ache (B) Burning
*
X
=
#
B
Patient/Guardian Signature
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