www.integratedphysio.com 604-732-6323 DATE______________
PHYSIOTHERAPY MEDICAL HISTORY FORM
ATTENTION: THIS FORM HELPS START DESCRIBING YOUR PROBLEM. YOU CAN DISCUSS DETAILS WITH THE THERAPIST!
DOB: D /M/Y)___/___/____
Was our clinic was recommended to you by a friend or relative, please let us know whom to thank: _________________________or how did you learn about out services? ______________________________
YOUR PRESENT PROBLEM or COMPLAINT: ______________________________________________________
Please list all current medications ___________________________________________________
Please list your frequent Hobbies, sports and physical activities:_______________________________________________
PLEASE CHECK OFF ALL THE ISSUES YOU MAY HAVE BELOW:
|Skin Condition||Pregnancy||Breathing Difficulties||High Blood Pressure|
|Heart Condition||Pacemaker||Deep Brain Stimulator||Arthritis|
|Osteoporosis||Chronic fatigue/Lyme’s||Bowel/Bladder problems||Concussion|
|Joint Replacements||Rapid Weight Loss||False Teeth||Sleep Apnea|
|Sleep positions:||Quality of Sleep (1-5):|
Are your injuries from a car accident: ___YES/NO__
Date of injury____________________
Are your injuries work related?__YES/NO___
Date of injury:________________________
Claim Number -WCB/ICBC)_________________________
Personal Health Number (MSP)_________________________
Date of Injury:_________________
Injured area (s)__________________________________________
How Injury happened: ________________________________________________________________________________________________________________________________________________________
Things that make problem worse:_____________________________
Fees and Cancellation Policy
Payment is collected at the end of each treatment. Cash, cheques, and credit cards accepted.
First session assessment & treatment: $135.00 ( 60 min) (valid for 12 months to date of last treatment).
If you wish to pay by Interac you must be able to access your on-line bank/credit union account to do an e-transfer to clinic account.
Subsequent treatments $120.00 (40-50 min)
Children under 13 years: $110.00 :
$130.00 for therapy for new health issues requiring reassessment within 12 months of previous last visit;
If you miss or cancel an appointment with less than 24 hours notice you will be charged $110.00; Health plans and insurers do not pay for missed appointments so you will have to pay the cost personally. Fees subject to change without notice.
Consent to treatment (to be signed after interview with therapist)
I, ___ ________________________________ understand that physiotherapy in being provided for the purpose of assisting with healing and/or function. My medical history is true and I will tell my therapist/assistant if any part of the medical history changes during the course of my treatment. I have been informed by of the benefits, risks, and potential side effects of treatment along with possible alternatives. I have the right to stop or change treatment at any time. I have read and understand this form and give my consent to begin treatment.
Client signature: _____________________________________________
Therapist’s signature:___________________________________________ Date:________________ 06012018