Body in Balance Physical Therapy Medical History Questionnaire

Name(Required)
MM slash DD slash YYYY

Have you ever been diagnosed as having any of the following conditions?

Heart Problems(Required)
Diabetes(Required)
Thyroid Problems(Required)
Epilepsy/Seizures(Required)
Cancer(Required)
Hypertension (high blood pressure)(Required)
Blood disorders (e.g. anemia, hemophilia)(Required)
Asthma/breathing problems(Required)
Gastrointestinal disorders(Required)
Neurological disorders(including stroke)(Required)
Arthritis(Required)
Attention deficit hyperactive disorder(Required)
Depression/Anxiety(Required)
Panic attacks(Required)

Have you recently experienced any of the following?

Change in bowel/bladder habits(Required)
Unexplained weight loss or gain(Required)

Have you been exposed to any communicable/infectious diseases? (e.g. Tuberculosis, Hepatitis, HIV)(Required)
Is there any possibility that you are currently pregnant?(Required)
MM slash DD slash YYYY
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