Patient Health | Physical Therapy Associates

Patient Information

In the past 3 months have you had or do you experience the following (Choose Yes or No)

Medication

List ALL current prescriptions, over the counter medications, herbal, vitamin/mineral/dietary (nutritional) supplements

MEDICATION NAME DOSAGE (ex. mg,ml, cc) FREQUENCY (ex. 3 times a day, 5 times a week) ROUTE OF ADMINISTRATION (ex. oral, injection, topical)