Medical Information Form                                                                                                                                                                           BACK HOME

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2. DATE OF ACCIDENT / CAUSE (accident; cancer; other - please describe)

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3. MEDICAL / SURGICAL HISTORY:

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-          HISTORY OF FRACTURES________________________________________________

-          WOUNDS, ULCERS______________________________________________________

-          PREVIOUS THERAPY____________________________________________________

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4. WHAT IS YOUR:

- HEIGHT          ________________________________________________________________

- WEIGHT          _______________________________________________________________

 

5. CIRCUMFERENCES OF:

CHEST_________________________

WAIST________________________

THIGH__________________________
 

6. MEDICAL STATUS:

- SENSATION / LOSS FOF FEELING______________________________________________

- SEIZURES (date of last one) ____________________________________________________

- SCOLIOSIS __________________________________________________________________

- HEART PROBLEMS / HYPERTENSION ____________ ______________________________

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-  SURGERIES_________________________________________________________________

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- LUNGS PROBLEMS___________________________________________________________ 

- DIABETES ___________________________________________________________________

- VISION/HEARING _____________________________________________________________

- SHUNTS (hydrocephalus) _____________________________________________________

- TRACHEAL/G- TUBE __________________________________________________________

- KIDNEY PROBLEMS___________________________________________________________

- SKIN PROBLEMS (ulcers, infections, inflammations)______________________________

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7. PLEASE PROVIDE PHONE NUMBERS TO ALL SPECIALISTS WHO TREAT YOU 

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8. PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING (and reason for taking)

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9. MOVEMENT ABILITIES (UPPER EXTREMITIES, HANDS, LOWER EXTREMITIES):

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10. LIST OF MEDICAL EQUIPMENT THAT YOU ARE USING:
    (braces, walker, crutches, wheelchair)

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11. DOES YOUR PHYSICIAN ADVISE YOU NOT TO PARTICIPATE IN
     INTENSIVE PHYSICAL ACTIVITIES (why? contraindication):

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12. PLEASE PROVIDE US WITH AVAILABLE WRITTEN TESTS, REPORTS (x-RAY, MRI, EMG)


PLEASE PRINT OUT AND MAIL OR FAX COMPLETED FORM TO:

Therasuit LLC
2141 Cass Lake Rd., Suite 107
Keego Harbor, MI 48320
Phone 248-706-1026 / 248-706-1308
Fax    248-706-1049
office@suittherapy.com