Aquatic Weight Loss

Rehabilitation Program

HealthPointe Aquatics Center

12727-12717 Ocean Hwy
Pawleys Island, SC 29585
Phone: (888) 555-5309
Fax:(888) 867-5309
Email: AWLRP@therapy.com

Patient Information Sheet

This form should be filled by the patient as completely as possible.
Full Name: ___________________________________

SSN:_____________________

Address: _____________________________________

D.O.B.: ___________________

_____________________________________
_____________________________________
Telephone number:_____________________________
Emergency contact #1:___________________________
___________________________
Emergency contact #2:___________________________
___________________________
Age: ___________________________

Place of birth: ____________________________

Race: __________________________

Military service: ___________________________

Marital Status: ____________________

Last year of school/degree:__________________

Occupation: ______________________
Primary Physician: ________________________________________

Past History
Medical: (give an approximate age you had any of the following)
____ German measles
____ Measles (7 day)
____ Mumps
____ Chicken pox
____ Whooping cough
____ Diptheria
____ Scarlet fever
____ Rheumatic fever
____ Poliomyelitis
____ Malaria
____ Typhoid fever
____ Infectious mono

____ Tonsilitis
____ Shingles
____ Influenza
____ Pneumonia
____ Pleurisy
____ Bronchitis
____ Tuberculosis
____ Emphysema
____ Sinus trouble
____ Hay fever
____ Asthma
____ Seizure

____ Nervous breakdown

____ Stroke
____ Glaucoma
____ Thyroid trouble
____ High blood pressure
____ Heart murmur
____ Heart trouble
____ Diabetes
____ Ulcer
____ Gall bladder issue
____ Hepatitis
____ Jaundice

____ Ear infections

____ Unconsciousness ____ Pancreatitis

____ Colitis
____ Kidney stone
____ Kidney trouble
____ Kidney infection
____ Bladder infection
____ Prostate trouble
____ Syphilis
____ Gonorrhea
____ Cancer
____ Gout
____ Arthritis
____ Anemia
____ Blood transfusion

Aquatic Weight Loss

Rehabilitation Program

HealthPointe Aquatics Center

12727-12717 Ocean Hwy
Pawleys Island, SC 29585
Phone: (888) 555-5309
Fax:(888) 867-5309
Email: AWLRP@therapy.com

Surgeries, Hospitalizations, or Injuries:

Date

Diagnosis

Doctors Name

Treatment

_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

Hospital

Medications: (describe medicines you commonly take, both over-the-counter and prescription
Name
Dose
How often
For what
Since when
_______
___________
__________
________________
______________
_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

_______
___________
______________

__________

________________

Allergies: (please describe any known allergies to medicines or foods, etc)

________________________________________________________________
________________________________________________________________
_________________________________________________________________
Immunizations: (give approximate year you had the following)
Baby shot _________

Tetanus __________

School shots _______

TB Skin test ________

Flu shot _________

Pneumonia _______

Habits: (please circle all correct answers)

Do you drink coffee?
Yes No
_______________________________

How many cups per day

Aquatic Weight Loss

Rehabilitation Program

HealthPointe Aquatics Center

12727-12717 Ocean Hwy
Pawleys Island, SC 29585
Phone: (888) 555-5309
Fax:(888) 867-5309
Email: AWLRP@therapy.com

I, the undersigned, hereby affirm that the information that I have provided above is correct to the best
of my knowledge and agree to allow the C.A.R.E.S. Clinic and its associates to use the information for
the prevention, diagnosis, or treatment of physical impairment.

______________________________

___________________________

___________

Patient Name (print)

Patient Signature

Date