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Patient Medical Profile Form
Patient Medical Profile Form
REQUIRED MEDICAL PROFILE INFORMATION
Date Last Reviewed by Patient
MM slash DD slash YYYY
Tobacco Use
Currently
Quit
Never Used
Falls in the last 6 months
Hospital, ER visits last 6 months
General Health
Poor
Fair
Good
Excellent
Patient Reported Activity Level
Sendentary
Limited Activity
Active
Very Active
Received Device within past 5 years?
Yes
No
Device Details
Allergies?
Height
Weight
Major Surgeries? If yes, please describe:
Cause
Accident from Employment
Auto Accident
Condition Since Birth
Other Medical Conditions
Alzheimers or Dementia
Anxiety
Asthma
Brain Injury (TBI)
Cancer
Depression
Diabetes Type 1
Diabetes Type 2
Hearing Loss
Heart Problems
Hepatitis
High Blood Pressure
HIV
Infections
Intestinal Problems
Kidney Disease
Liver Disease
Migraines
MRSA
Neurological Problems
Obesity
Osteoarthritis
Osteoporosis
Parkinson's Disease
Pulmonary Disease (TB)
Rheumatoid Arthritis
Seizure Disorders
Skin Problems
Stomach Problems
Stroke/TIA/CVA
Vascular Disease
Vision Problems
Currently Taking Pain Medication?
Yes
No
Amputations? Please Describe:
Other Conditions? Please Describe:
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