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Hansen Physical Therapy, PLLC – Medical Screeningdavid2020-08-07T19:30:47-04:00

Medical History Screening - Hansen Physical Therapy, PLLC

For patients of Hansen Physical Therapy, PLLC
  • Medical History Form

    This form can be filled out and saved online. At any time when filling the form, if you can scroll to the bottom and click "Save and Continue Later". After completing the form you can print or save a PDF copy.
  • Date Format: MM slash DD slash YYYY
  • We need your email address for you to be able to save this form.
  • Date Format: MM slash DD slash YYYY
  • Medical History Screening

  • Please indicate whether you have, or have had any of the following problems; include dates. This information will help us create a safe effective treatment plan. Certain types of therapy are not used depending on your medical status/history.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Home/Work Environment

  • This field is for validation purposes and should be left unchanged.
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Contact Info

1 Kennedy Drive U3-4
South Burlington, VT 05403

Phone: 802-863-3323

Fax: 802-863-3288

Email: Email Us

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