Client History Questions – Rehabilitation and Integrative Medicine

Prior to your appointment with our Rehabilitation and Integrative Medicine Department, please complete and submit the following form. Thank you and we look forward to seeing you at your upcoming appointment.

  • (If yes, please list them.)
  • (Run, jump, stairs, play?)
  • Click the "+" button to add additional medications.
    Drug NameConcentration (mg/ml or mg/tablet)Number of tablets or ml per doseFrequency 
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