Pre-assessment Upper Body Form 2017-12-14T15:37:48+00:00

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT

Upper 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.
  • Upper Extremity Functional Scale

  • Today, do you or would you have difficulty at all with:
  • Medical Information Release Form

 

Verification