First Name *

Last Name *

Occupation

Gender

DOB *

Height

Weight

Address *

City *

Zip / Postal code *

Email *

Would you like email appointment reminders?

Yes

No

Home Phone # *

Secondary Phone # *

Family Dr *

City

Doctor Phone #

Doctor Fax #

Referral Source *

Emergency Contact Name:

Emergency Phone # *

Relationship to patient

(If Applicable) WSIB (Workplace Injury) patients

Are you a WSIB patient? *

Yes

No

(If Applicable) MVA (Motor Vehicle Accident) Patients

Are you an MVA patient? *

Yes

No

Lawyer Information

Name of Law Firm

Name of Lawyer

Lawyer Address

Lawyer Phone #

Lawyer Fax #

Lawyer Email

Physiotherapy

Rehab Information

Chief Complaint/Ailment/Injury

Have you had any past history of Accidents (MVA(Motor Vehicle Accident), WSIB(Workplace Injury), Slips & Fall)?

Yes

No

If yes (Please mark which applies)?

WSIB (Workplace Injury)

MVA(Motor Vehicle Accident)

Slip & Fall

If yes, when?

Have you had any past history of Trauma or Fractures?

Any current Metal/ Mesh Implantations?

Yes

No

Describe

Date of Injury

Date of Surgery

Briefly describe how you were injured?

Have you received therapy for this condition?

Yes

No

When

Has your condition been getting

Worse

Same

Better

Are your symptoms?

Constant

Intermittent

Make the number that best corresponds to your pain At Best

1

2

3

4

5

6

7

8

9

10

Make the number that best corresponds to your pain At Worst

1

2

3

4

5

6

7

8

9

10

What decreases/ makes your condition better? (Mark all that apply)

Bending

Sitting

Raising

Changing positions

Movement

Standing

Walking

Lying

Rest

Heat

Ice

Medication

Better in AM

Better as day progresses

Better in PM

N/A Cast just removed

Notes

What increases/ makes your condition worse? (Mark all that apply)

Bending

Movement

Resting

Sneeze

Sitting

Standing

Stairs

Deep Breaths

Raising

Medications

Lying

Worse in AM

Worse in PM

Worse as day progresses

Prolonged Positioning

Previous Medical Intervention (make all that apply)

X- Ray / MRI

CT Scan

Other

Location of Imaging

What are your goals to be achieved by the end of therapy?

Lifestyle Questions – Please complete the following

Medical information (make all that apply) ** This information is confidential and remains part of your chart **

Difficulty Swallowing

Motion Sickness

Stroke

Arthritis

Fever/Chills/Sweats

Osteoporosis

High Blood Pressure

Unexplained Weight Loss

Anemia

Heart Trouble

Blood Clots

Bleeding Problems

Pacemaker

Shortness of Breath

HIV/Hepatitis

Epilepsy/Seizures

History of Smoking

History of Alcohol Abuse

History of Drug Abuse

Diabetes

Depression / Anxiety

Myofascial Pain

Fibromyalgia

STD

Cancer

Skin Diseases

Are you Pregnant?

Yes

No

If yes, how far along?

Previous Surgeries

Other

Medications

Allergies

Signature

Patient’s Signature (or guardian)

Clear

Date