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Momentum Physical Therapy PAST MEDICAL HISTORY FORM Patient Name Date Yes Are you presently working Date of injury / onset / No Date of next physician s visit Have you ever had these symptoms before Check which apply to your symptoms Work related injury Recurrence of previous injury Motor vehicle accident Injury related to lifting Cause unknown Athletic / recreational injury Have you had a related surgery Other Do you have or have you had any of the following Diabetes Chest Pain / Angina High...
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Mr. Jones the next part of the interview is past medical history and what I want to talk with you about here is things that have happened in the past with you diseases that you can remember since you were a child the first question that I want to talk with you about is as an adult when you think back to your childhood are there any illnesses that you've had diagnosed as an adult nah not really all right when you think back on your childhood are there or did you have the normal childhood the routine childhood illnesses or were you vaccinated against them either one on the first site I got you know the normal like chickenpox etc but no vaccinations all right any medications that you take every day I take a few okay what do you take um there is the I'm blanking on the name but it it's it's for allergies and you take it every day claritin you take care Clinton every day yes okay and does that work for your allergies does that help you okay any other medicines that you take every day um I have to take a propecia okay and what is that for it's for hair loss okay anything else no okay have you ever had surgery no no have you ever had any major injuries that took you to the hospital or made you seek medical care um broke my finger once but other than that which finger the index on your right right index okay and how did you break that basketball basketball how long ago was that oh seven years ago okay have you had any problems with it since no okay ever been in the hospital other than when you were born no no okay are you up-to-date on all your immunizations mm-hmm okay are you allergic to any medications um Penniston to penicillin and what happens when you take penicillin um I get really cold shake a lot it's no fun okay all right you mentioned that you take claritin for allergies are those seasonal allergies yeah okay do you know what they are I don't know are you allergic to anything else no okay