Client Intake Form - The Sharpe Physiotherapy & Massage Clinic
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2CLIENT INTAKE FORM
Name
Date of Birth
Date Today
Phone-Home
Work
Cell
email
Address
City
Postal code
Family Dr.
Specialist
Referred by :
Self
friend
Do you have extended health coverage ?
company
amount
physio,
acupuncture
massage
therapy
Veterans affairs
Wsib
Mva
K Number
Claim #
Claim #
Occupation – present/past
If wsib,- employer address/ph
If mva- adjuster and ph #
What is the problem you wish assessed today: please circle below
Neck
upper back
low back
bladder problems
fitness
Dizziness
mobility
gait
headaches
Right or left -R /L
Shoulder
elbow
hand
fingers
Hip
knee
foot
Other:
Present since,
Commenced as a result of
Better:
sitting, standing, lying, walking
Worse: sitting, standing lying , walking
am/ as day progresses/pm other
am/ as day progress/ pm
other
tingling,
numbness,
Difficulty sleeping
constant
intermittent
Previous or present treatment by:
Physiotherapy
chiropractor
massage therapy
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