Pre-assesement Neck Form 2017-12-14T15:25:02+00:00

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT

Neck Form

  • ONLY IF WSIB

  • Medical/Surgical History

  • Symptoms

  • P4 Pain Intensity Measure

  • When answering these questions, think only of the pain you are experiencing in relation to the problem for which you are having treatment. Check one number for each of the four questions. On average, how bad has your pain been.
  • Neck Disability Index

  • Please check in each section the one box that applies to you. Although two of the statements in any one section may relate to you, please check the box the most closely describes your present day situation.
  • Medical Information Release Form

 

Verification