Treatment Status - Helene Price


CLIENT NAME:


DATE OF ACCIDENT: ______ /______ /______

DATE:


FILE NO.: ________

NAME, ADDRESS AND TELEPHONE NUMBER OF DOCTOR YOU ARE CURRENTLY TREATING WITH:

HOW OFTEN ARE YOU RECEIVING PHYSICAL THERAPY?

ARE YOU TREATING WITH ANY SPECIALIST?

IF SO, LIST NAME, ADDRESS AND TELEPHONE NUMBER OF SPECIALIST:

PRESENT COMPLAINTS:

DO YOU HAVE ANY TINGLING, NUMBNESS OR FALLING ASLEEP SENSATIONS IN YOUR ARMS OR LEGS?

ARE YOU SATISFIED WITH THE TREATMENT YOU ARE RECEIVING FROM YOUR DOCTOR?

HAVE YOU COMPLETED YOUR TREATMENT?

IF SO, WHEN WHERE YOU FORMALLY DISCHARGED?

DID YOU MISS TIME FROM WORK?

IF SO, LIST DATES YOU MISSED FROM WORK

Leave this empty:

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Document name: Treatment Status - Helene Price
lock iconUnique Document ID: e41ce48fffbfa0f837c86b26f16643e01e0e7708
Timestamp Audit
May 20, 2020 7:21 pm GMTTreatment Status - Helene Price Uploaded by David Rosenbaum - test@rosenbaumfirm.com IP 68.80.162.82
May 20, 2020 11:57 pm GMTHelene Price - hprice@rosenbaumfirm.com added by David Rosenbaum - test@rosenbaumfirm.com as a CC'd Recipient Ip: 68.80.162.82