Past medical history Past Medical History Please fill out the form below. Name First Last Date MM slash DD slash YYYY Are you working? Yes No Who is your employer? Date of Injury / Onset: MM slash DD slash YYYY Have you ever had these symptoms before? Yes No Check which apply to your symptoms:*On computer please hold control button when making multiple selections.Work related injuryMotor vehicle accidentCause unknownRecurrence of previous injuryInjury related to liftingAthletic / recreational injuryInjury related to fallingHave you had a related injury? Yes No Please check if you have or have had any of the following?*On computer please hold control button when making multiple selections.DiabetesChest Pain / AnginaHigh Blood PressureHeart DiseaseHeart AttackHeart PalpitationsPacemakerHeadachesKidney ProblemsAre you pregnant?CancerOsteoporosisBowel / Bladder AbnormalitiesUrine LeakageAsthma / Breathing DifficultiesLiver / Gallbladder ProblemsSmokingStroke / CVAAllergies to AspirinAllergies to HeatAllergies / Poor tolerance to ColdOther AllergiesHerniaSeizuresMetal ImplantsDizziness / FaintingRecent FracturesSurgeriesSkin AbnormalitiesSexual DysfunctionNausea / VomitingRinging in your earsRheumatoid ArthritisSpecial Diet GuidelinesHypoglycemiaHistory of MRSA colonizationIf you selected any of the above, please briefly explain and give approximated date:Is there any other information regarding your past medical history that we should know about?If yes, please list what medications and for what reason:
