SIMI PHYSICAL THERAPY CENTER

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					                                         SIMI PHYSICAL THERAPY CENTER
                                    PATIENT INFORMATION & BRIEF HISTORY
              (Federal regulation required a medical history must be included in all patients’ medical records)


Date _______________Name ________________________________________________________________________
                                 Last                          First                  M. I.
Home Address _____________________________________City ____________________State ______ Zip _________
Primary Care Dr. ___________________Referring Dr._____________________ Employer _______________________
Employer Address __________________________________City ____________________State ______Zip __________
Home Phone _____________________Work Phone ___________________Referring Dr. Phone __________________
Soc. Sec. # __________________________________Drivers License # _______________________________________
Sex F__________ M ___________ Marital Status S____ M____ D____ W____ Birth Date ____________Age _____
Emergency contact and phone: ________________________ How did you hear about us? _______________________


                                              ACCIDENT INFORMATION

Where did accident happen? Work______ Automobile ______Home ______ Date of Accident ____________________
If automobile accident: Insurance Co. ________________________________________________________________
Agents Name ________________________________ Phone No. ____________________________________________


                                              BRIEF MEDICAL HISTORY

Have you had previous physical therapy for your present condition for which you request treatment? Yes____ No _____
If yes, where? _______________________________________________ When ________________________________

Do you now have or had any of the following? (Circle answer):

Diabetes                    Yes         No                    Kidney problems                      Yes        No
High Blood Pressure         Yes         No                    Heart Attack                         Yes        No
Heart Disease               Yes         No                    Headaches                            Yes        No
Sensitive to heat/ice       Yes         No                    Pregnant (now)                       Yes        No
Allergies                   Yes         No                    Hernia (ventral, inguinal, etc.)     Yes        No
Pacemaker                   Yes         No                    Metal Implants                       Yes        No
Cancer                      Yes         No                    Nervous disorders                    Yes        No
Previous Surgeries          Yes         No                    Stroke or Seizures                   Yes        No


If yes on any of above, please explain and give appropriate dates: __________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Are you presently taking medication: Yes ____ No ____. If yes, list what medication and for what condition:
________________________________________________________________________________________________
________________________________________________________________________________________________


The above information is correct to the best of my knowledge.

I hereby authorize Simi Physical Therapy Center to furnish the insurance company or others not authorized by law, with
full in formation regarding treatment rendered, when so requested.

I hereby authorize my insurance company to pay directly to Simi Physical Therapy Center medical benefits otherwise
payable to me and I will be responsible to Simi Physical Therapy for all expenses incidental to treatment rendered not paid
under this plan. A photocopy of this assignment may be used in lieu of the original.

Date _______________________________ Signed ______________________________________________________
                                             (Patient, or parent, if patient is a minor)

				
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