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Evens PT Collective

Patient Forms

Please fill out and submit the following form prior to your first visit. Thank you!

Medical History

First name*

Last name*

Email*

Date of birth*

Month

Day

Year

In the past 6 months, have you had:

Difficulty with bowel/bladder control?

Yes

Numbness?

Yes

Numbness in the genital or anal area?

Yes

Weakness?

Yes

Vision and/or hearing problems?

Yes

Dizziness or fainting?

Yes

Unexplained weight change?

Yes

Chest pain?

Yes

Have you ever been diagnosed as having any of the following:

Cancer?

Yes

If yes, what kind?

Heart problems?

Yes

Rheumatoid arthritis?

Yes

Chemical dependency/alcoholism?

Yes

Heart problems?

Yes

High Blood Pressure?

Yes

Osteoarthritis?

Yes

Anxiety or panic disorders?

Yes

Stroke?

Yes

Hepatitis/HIV/AIDS?

Yes

Depression?

Yes

Neurologic disease?

Yes

If yes, please specify:

Diabetes?

Yes

Other:

Please list any surgeries or conditions for which you have been hospitalized and may pertain to your current condition. Please include the surgery date and reason for hospitalization:

What medications including prescriptions, herbal remedies and over the counter, in any form (pills, injections, skin patches) are you currently taking?

Alcohol consumption (# of drinks) per week:

Cigarettes and/or cigars per week:

I declare that the info I’ve provided is accurate and complete.

CONTACT EVENS PHYSICAL THERAPY COLLECTIVE

Address

2753 NW Lolo Dr.
Bend, OR 97703

Contact

p: 541-285-7070

f: 541-550-1145

evensphysicaltherapy@gmail.com

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Last Name

Phone

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