Medical History

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Medical History Form

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First Name

Last Name

Address

Gender

Male

Female

Birth Date

Height (Feet & Inches)

Weight (lbs.)

Presenting Problems or Diagnosis

How many hours of strenuous exercise do you get each week (for example weight lifting, running, cardio, yoga, biking)

Where is the pain you want treated by this procedure?

What does this problem prevent you from doing?

Please list any prior surgeries to this area:

Other types of care you have had for this problem:

What diagnoses, if any, have your doctors given you?

Other health history: including problems you take medications for, see a doctor for, have had surgery for, that have caused you to be hospitalized, or any history of communicable diseases?

What medications do you take. Please list prescription, over the counter medications and any supplements.

Convenient Locations Near You

Rehabilitation Medicine Center of New Jersey, PA

1350 State Route 23, 2nd Floor

Wayne, N.J. 07470

877-708-2565

New York Office – Rehabilitation Medicine Center of New Jersey, PA

131 West 35th Street, 12th Floor

New York, NY 10001

877-708-2565