In order for the practitioners to provide you with the best possible care the following confidential information must be compl

In order for the practitioners to provide you with the best possible care the following confidential information must be completed.
Patient’s Full Name:_________________________________________________________________________________ Date of Birth:______________________________________________________________________________________ Address:_______________________________________________________________ Postal Code:________________ City:_____________________________________ Province:________________________________________________ Home phone:______________________________ Work phone:_____________________________________________ Occupation:_______________________________ Employer:_______________________________________________ Email Address:_____________________________________________________________________________________ Would you like to subscribe to our quarterly newsletter? YES NO Referred by:_______________________________________________________________________________________ Have you worked with a trainer/athletic therapist before? ___________ If yes, who and where? _________________________________________________________________________________________________ What is your main concern?___________________________________________________________________________ When did it begin?__________________________________________________________________________________ Have you had this or a similar complaint before?______________ If yes, explain: _________________________________________________________________________________________________ Does anything aggravate it?___________________________________________________________________________ Does anything make it better?_________________________________________________________________________ How often does the complaint occur?___________________________________________________________________ How long does it last?_______________________________________________________________________________ Does the complaint interfere with your: (circle all that apply) Activities/movements difficult to perform? (circle all that apply) Have you received any other treatment for your complaint?___________ If yes, please specify from the following: Other:____________________________________ Are there any other concerns/complaints?________________________________________________________________ Past History
_____________
Surgeries:____________________________________________________________________________________ Injuries:_____________________________________________________________________________________ Auto accidents:_______________________________________________________________________________ Hospitalizations:______________________________________________________________________________ Major illnesses:_______________________________________________________________________________ Are you currently taking any medications? (include asprin, ibuprofen, antihistamines, birth control, supplements, etc…)__________________________________________________________________________________________________________________________________________________________________________________________________ Do you have any allergies?_________________________________________________________________________________________________ Do you have any medical conditions? (circle all that apply) Name of your medical Doctor: _______________________________________________________________________ What are the main goals you want to accomplish with your visit(s) to Physical Solutions: 1.__________________________________________________________________________________________ 2.__________________________________________________________________________________________ 3.__________________________________________________________________________________________ REVIEW OF SYSTEMS
Circle any of the following that you currently have or have experienced in the past 6 months: ARMS AND HANDS
HIPS/LEGS/FEET
MOUTH/JAW/THROAT
Fee Guidelines
It is policy of Physical Solutions Rehabilitation and Personal Training that regardless of the patient’s individual health insurance coverage for athletic therapy, payment must be made a time of service. Receipts are provided for the patient to arrange reimbursement. Our athletic therapist is registered with the Canadian Athletic therapist Association.
* PACKAGES HAVE AN EXPIRY DATE OF 1 YEAR FROM TIME OF PURCHASE *
* NO REFUNDS *
*CANCELLATIONS WITHOUT 24 HOUR NOTICE AND NO SHOWS WILL RESULT
IN A CHARGE FOR THE SCHEDULED SESSION *
I have stated all medical conditions that I am aware of and will update the practitioner of any changes in my health status. I agree to immediately inform the therapist if I experience any pain or discomfort during my treatment/training session so that the rehabilitation/treatment/training can be adjusted to my level of comfort. I assume all risks and responsibilities from any injury or liability that may occur as a result of this session.
Date:_____________________________________________ Signature:_________________________________________

Source: http://www.physicalsolutions.ca/files/New%20Patient%20form.2013.pdf