Medical History Form

Date of Birth(Required)

Cell Phone(Required)

Home or Work Phone(Required)

Your Email Address(Required)

Employer Name (if applicable)

Insurance Company Name

Primary Subscriber's Name (i.e. spouse or parent)

Primary Subscriber's Date of Birth

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Primary Care Physician(Required)

Chief Complaint(Required)

Date of Injury (if applicable)

List Current Medications

List any Sports or Recreational Activities

Describe your exercise . How many times per week?

How many cigarettes do you smoke daily on average?(Required)

How much alcohol do you consume daily on average?(Required)

How many caffeinated beverages do you consume daily on average?(Required)

How many ounces of water do you consume daily on average?(Required)

List other Medical Conditions

I hereby agree and give my consent to medical treatment in treating my physical condition. I authorize the release of any medical information needed to process my claim. I understand that I am responsible for any charges that are not covered by my insurance carrier. Furthermore, I understand that I am responsible to inform the office of any changes that occur. I authorize the release of payment directly to Optimal Physical Therapy, LLC, regardless of participation in or out-of-network. Should I default on my financial responsibility and collection action is necessary, I will be responsible for collection costs that are incurred.

I acknowledge that I have seen the “Notice of Privacy Practices.” I understand that I may ask questions about the “Notice of Privacy Practices” at any time.

I have read the terms and by signing below I am indicating that I understand the terms.

Date

First Name(Required)

Medical History Form

Medical History

Words from Our Patients

Your Health is Our Top Priority

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Medical History Form

Medical History Form

Medical History

Words from Our Patients

Your Health is Our Top Priority

Use the QR Code below to Pay

Subscribe now