The purpose of this form is to help the Physical Therapist understand your health status. Please complete the questionnaire to the best of your ability. This form will be a part of your medical record. A Medical History Questionnaire is required at the opening of each new case.
Rate your pain over the last week on a scale of 0 – 10(0 = No pain at all, 10 = Need to go to the emergency room):
I, the patient/guardian for this Medical History Questionnaire, warrant the truthfulness of the information provided in this application.
155 W. Duval Rd. Green Valley, AZ 85614 Phone: (520) 648-3132 FAX: (520) 648-1861
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