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Aquatic Physical Therapy & Beyond, LLC
Patient Medical History


Name:                                                  Date: 
Do you presently have or have you previously had heart problems? 
          If yes, check all that apply.  
  Heart Attack How Many?    When?
  Chest Pain          Congestive Heart Failure          Abnormal Heart Rate
  Pacemaker Fast Slow Irregular   When?
  Heart Surgery Angioplasty (Balloon)    When?
    By-Pass   When?
              Other  When?
  Other Heart Problems Specify:   
If you presently have or have previously had any of the following conditions, check all that apply
  Asthma          Emphysema          Chronic Obstructive Pulmonary Disease (COPD)
  Shortness of Breath  
  Other Breathing Problems
  Circulatory Problems  
  Back or Neck Problems
               Surgeries and Dates:
       Other Orthopedic Problems
                 Surgeries and Dates:
  High Blood Pressure
  Degenerative Joint Disease (DJD)/Osteoarthitis
  Rheumatoid Arthritis
  Pregnancy (currently)
  Recent Surgeries not mentioned above
         Type:           Date:
Are you allergic to any drugs/medications?    If so, please list below: 
List the medications are you currently taking?
Patient Initials:       Date:     Patient Signature after printing:__________________________
If you use an inhaler, take Nitroglycerine tablets or any other emergency medication please bring it
with you to each appt & let your treating therapist know

Therapist Signature
: ___________________________________________________________