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Get Farese Physical Therapy Patient Medical History Form

Ifting, sitting, standing, etc.____________________________ 3. Height __________________ Weight ____________ Do you Smoke Yes No 4. Past Medical History – Do you have a history of: High Blood Pressure Heart Condition Strokes Osteoarthritis Lupus Yes Yes Yes Yes Yes No No No No No 5. Previous medical problems or surgeries? Pacemaker Yes No Yes No Currently Pregnant Yes No Seizures Diabetes Yes No Cancer Yes No Yes No HIV or AIDS Fibromyalgia Yes No Allergies Yes No Internal Fixation Dev.

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