Medical History Form

"*" indicates required fields

Name*

First Last

Date of Birth*

Email*

Phone*

Please list any conditions that apply to you or any member of your immediate relatives:

Are you currently taking any medication? If so, please list them:

Have you fallen in the past year? Y/N

Do you use any kind of tobacco or have you ever used them? Y/N

Have you been able to perform fitness activities? Y/N If yes, please describe.

You will have a chance to go more in depth with the therapist, but please briefly describe your reason for seeking out physical therapy:

Signature*

Date*

Simplify Motion offers in-home physical therapy services with personalized care plans to improve mobility and recovery.

PO Box 15823

Phoenix, AZ 85060

Start your rehabilitation journey with Simplify Motion Physical Therapy today.