Physiotherapy Medical History Form
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1
2Physiotherapy Medical History Form
Name (first/last)
Birthdate (D/M/Y):
Address:
City:
Postal code:
Home:
Work :
Cell:
Email address:
Emergency contact:
Phone
Referring physician:
Family physician:
How did you hear about our clinic?
Please list any previous accidents or injuries.
Please list all current medications:
Private health insurance varies please check with yours to ensure you know what is covered.
Insurance company:
P olicy number:
ID number:
Please check off any of the following issues that you may have.
ᴏ Skin conditions
ᴏ Pregnancy
ᴏ Breathing difficulties
ᴏ High blood pressure
ᴏ Heart disease
ᴏ Pacemaker
ᴏ Deep brain stimulator
ᴏ Arthritis
ᴏ Osteoporosis
ᴏ Chronic fatigue syndrome
ᴏ Bowel/bladder problems
ᴏ Fibromyalgia
ᴏ Diabetes
ᴏ Stroke
ᴏ Caner or malignancy
ᴏ Numbness
ᴏ Joint replacements
ᴏ Rapid weight loss
Are your injuries related to a car accident?
Date of accident
If yes please complete car accident forms
Are you injuries work related?
Health Card number
If yes please complete WCB forms
Injury
Area injured
How injury happened?
Date injured
Things that make the pain better?
Things that make the pain worse?
Things I can’t do due to injury
Other information about injury
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Parent category: Medical