PHYSIOTHERAPY INTAKE FORM | Competitive Edge Physiotherapy

Intake Form

Last Name*

First Name*

Address*

City*

Province*

Postal Code*

Telephone (Cell)*

Telephone (Home)

Email Address*

Date of Birth*

Emergency Contact*

Relation*

Emergency Contact Telephone (Home):*

Emergency Contact Telephone (Cell):

Family Doctor Name

Family Doctor Telephone

Is this your first time at our clinic?

Yes
No

*If no, date of last visit

How did you get injured?

Car Accident
Work

Date of Injury

How did you hear about our clinic?*

Examples: Referred by a doctor, referred by friend/colleague/family, advertising (brochures, banner, etc.), by chance/walk in, by employee staff, internet search, returning patient

Confidential Health History Form

Please briefly write in your words the primary reason for your physiotherapy consult: (e.g. back & leg pain)

Are you taking any medication currently?*

(Please answer NO or list if any)

FOR WOMEN: Are you currently pregnant or think you might be pregnant?

Do you currently have or have had a history of any medical condition(s)? Please check all that apply)*

If you selected allergies in the previous question, please list them below:

Have you had any surgeries? If so, please list them:

Within the past year, have you had any of the following symptoms? (Please check all that apply)*

Have you recently had any unexplained weight loss? Loss of appetite? Night sweats?*

Yes
No

Do you have unrelenting/constant night pain?*

Yes
No

Do you have a history of oral steroid use? (e.g. cortisone, prednisone)*

Yes
No

During the last month, have you often been bothered by feeling down, depressed or hopeless?*

Yes
No

During the last month, have you often been bothered by little interest or pleasure in doing things?*

Yes
No

Please tell us what your (3) primary goals are or what you wish to achieve with your treatments: (e.g. return to playing tennis 3x a week, return to my full-time work as of…,be able to walk for 30 minutes, eliminate headaches)

Authorization for Submission & Direct Payment

Please fill out form ONLY if we bill directly to your insurance company. List can be found in FAQ. Please put N/A if not applicable.

Insurance Coverage*

No Coverage
Yes, but will submit myself
Yes, complete details below

If "No" or "will submit myself" please skip to the next section.

Insurance Company*

Insured Member Name

First Last

Insured Member Date of Birth

Extended Health Care PLAN/CONTRACT Number:

Extended Health Care Member I.D/CERTIFICATE Number:

I, _________________________, hereby authorize Competitive Edge Physiotherapy & Sports Conditioning to submit to my health care benefits on my behalf, and assign the payment for my health care benefits, as per the enclosed invoice, directly to Competitive Edge Physiotherapy & Sports Conditioning. As an EHC client, should any submitted claims deem unplayable, I agree that I will be held responsible to pay any outstanding balance for services rendered with the Corporation of Competitive Edge Physiotherapy & Sport Conditioning (CE Physio). Please be advised the authorization form for submission & direct payment will be valid until discharge and all accounts have been cleared. I have read and understand.

Please print out your FULL name.
Thank you kindly for your cooperation with this matter.

Visual Analog Scale

Referring to the drawings below, please indicate where you are experiencing pain by describing the area of injury, and the scale number for your current level of pain. Please list where you are feeling the pain (I.E. neck, back, shoulder, etc.) .

1st Area of Injury & Pain Scale*

Please refer to above picture for the answer to this question.

2nd Area of Injury & Pain Scale*

Please refer to above picture for the answer to this question.

3rd Area of Injury & Pain Scale*

Please refer to above picture for the answer to this question.

Consent for Physiotherapy

Please Read Carefully I, the undersigned, do hereby give my voluntary consent for the administration of Physiotherapy deemed appropriate by my treating Physiotherapist. I understand that Physiotherapy treatments may include an individualized exercise prescription and various forms of manual therapy techniques such as mobilization, manipulation, soft tissue release and stretches. Treatments may also include modalities such as heat, ice, therapeutic taping, ultrasound, laser, TENS, interferential current, shock wave and electrical muscular stimulation. Other treatment options include acupuncture/dry needling that involves the insertion of single use, sterile, disposable needles through the skin, into the underlying muscles. I understand that the primary goals of Physiotherapy treatments are to help reduce my pain and improve my mobility, strength, endurance, function and quality of life. I understand that there are very small possibilities of risks or complications that may result from the above listed treatments. I do not expect the Physiotherapist to anticipate all the possible risks and complications. I wish to rely on the Physiotherapist to exercise proper judgment during the course of treatment to make decisions based upon my best interest. Potential small but possible risk factors: Manual Therapy: Joint and/or muscle soreness Exercise Therapy: Joint and/or muscle soreness Electrical modalities: Minor skin irritations such as redness or a rash Therapeutic Taping: Minor skin irritations such as redness or a rash Acupuncture/Dry needling: Minor soreness, bleeding or bruising, nausea, fainting, infection, shock convulsions, possible perforation of internal organs, stuck or bend needles, and fetal distress in pregnant women I will immediately notify the Physiotherapist of any changes in my pregnancy or medical status. I will have the opportunity to discuss with my Physiotherapist the nature and purposes of all my treatments. I accept the fact that there is no guarantee of the effectiveness of the treatment. I am aware that I may withdraw this consent and discontinue treatment at any time. I consent to the Physiotherapy treatments offered or recommended to me by my Physiotherapist(s). I intend this consent to apply to all my present and future Physiotherapy care.*

Please input your FULL NAME here!

Date*

CANCELLATION & NO SHOW: WE REQUIRE 24 HOURS NOTICE OF CANCELATION. WHEN NO CANCELATION NOTICE IS GIVEN YOU WILL BE CHARGED A $20.00 FEE. THIS APPLIES TO ALL APPOINTMENTS FOR ALL OUR SERVICES OFFERED. I (PLEASE INSERT NAME BELOW) GIVE PERMISSION TO COMPETITIVE EDGE PHYSIOTHERAPY & SPORTS CONDITIONING TO RELEASE ANY INFORMATION REGARDING MY HEALTH AND REHABILITATION TO MY FAMILY DOCTOR, INSURANCE COMPANY OR LAWYER. I AM ALSO RESPONSIBLE FOR THE FULL PAYMENT OF MY TREATMENT. I FULLY UNDERSTAND THE CLINIC POLICIES AND AGREE TO ABIDE BY THEM*

Yes
No

Comments

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