Medical History
Patient name Date

Present Illness:

For what condition or symptoms are you being seen for at this time?

 

When did this condition begin?

 

What treatment have you already received?

 

Has this problem occurred in the past?

 

Past Medical History:

Please indicate whether you or your family member has had the following conditions:

  You Family
Cancer
Heart Disease
Arthritis
High Blood Pressure
Bleeding Tendency
Diabetes
Stroke
Gout
Epilepsy
Kidney or Bladder Problems
Respiratory Disease
Pneumonia /Emphysema
Hepatitis
Asthma
Jaundice
Hernia
Thyroid Disorder
Congenital Disorder
Are you pregnant?
y n
Do you have a pacemaker?
y n
Do you have any surgical implants?
y n

Please list all surgeries, including approximate dates:

 

Please list any procedures, fractures, or serious injuries (including previous car accidents with injuries):

 

Please list any allergies (including medications, latex, topical ointments, iodine foods, etc.):

 

Please list all medications and indicate for what condition they are being taken:

 

Please provide us with all information about your insurance coverage at the time of the first visit to our office.

We wish to stress that the financial responsibility for the services rendered rests with the patient or their family, regardless of any insurance coverage. Remember that very few insurance policies pay 100% of bills submitted. Please review your individual policy concerning physical therapy coverage.

In cases where the financial coverage for your care is being handled through an attorney, we must have a lien form signed by both the attorney and the patient. For treatment to continue uninterrupted, this form must be completed in a reasonable time. In those legally involved cases due to long payment delay, a 1.6% monthly interest charge will be added.

Patient medical information to insurance companies, attorneys, etc., will not be given over the telephone under any circumstances. This is for your protection. In order to release any information, we must have a release signed by the patient, indicating to whom we may release information.



Patient Signature Date



Complete Therapy USA Inc.Contact
Address 2627 NE 203 St., Suite 110,
Aventura, Florida, 33180
Phone
305-466-1388
Fax
305-466-9200