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Health Questionnaire

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Name

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Please list ALL current and past medical conditions you have experienced. Please include any and all systemic illnesses, injuries, surgeries, and chronic conditions (Note: Please do not exclude anything that you think is irrelevant, it may be relevant to PT).*

Please list all medications. This is very important as medications can affect PT treatment, and PT treatment can alter the therapeutic effect and/or metabolism of medications.*

Please describe the issue for which you are seeking assistance.*

Name*

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Email*

Signature*

Date*

Where to find us

Points North Sports & Regenerative PT
435 Points North Rd.
Stowe, VT 05672

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Phone: (203) 260-0215
Fax: (802) 264-8519
Email: info@pointsnorthphysicaltherapy.com