Pre-assessment Lower Body Form 2017-12-14T16:15:31+00:00

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT

Lower Body 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.
  • Lower Extremity Functional Scale

  • We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity. Today, do you or would you have any difficulty at all with:
  • Medical Information Release Form

 

Verification