HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT

PLEASE READ OUR PRIVACY POLICY INFORMATION FOR PATIENT

Neck Form

First Name *
Preferred Name *
Last Name *
Date of Birth (MMDDYY) *
Weight *
Height *
Foot Size *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Sex: *
MaleFemaleOther
Home Phone *
Cell Phone:
Work Phone:
Email *
Employer *
Occupation *
Family Physician *
Referral Source *

ONLY IF WSIB

OHIP Number
Social Insurance Number

Medical/Surgical History

Please check if you have ever had any of the following.Heart TroubleHigh Blood PressureBleeding DisorderEpilepsyStrokeSleep DisorderBack InjuryAllergiesArthritisDiabetesFractureCancerMVA InjuryInfectious DiseaseStomach UlcersHead InjuryDepression/AnxietyOsteoporosisThyroid ProblemsWSIB InjuriesLung ProblemsNervous DisordersPacemakerProstrate/Pelvice
Please give an appropriate date of onset of each condition you've selected

Symptoms

Please check if you have ever had any of the following symptomsJoint Pain or swellingDifficulty walkingDizziness/blackoutsWeight loss or gainWeakness in arms/legsPain at nightDifficulty sleepingHearing problemsShortness of breathHeadachesChest PainVision problemsLoss of balanceBowel/bladder problems
Please give appropriate date of onset of each sympton if applicable
Have you ever had surgery? *
YesNo
If yes please describe, and include dates (month, year)
Please list any medications you currently taking (including Advil, Tylenol, ibuprofen, etc.)

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.
In the morning over the past 2 days? *
012345678910
In the afternoon over the past 2 day? *
012345678910
In the evening over the past 2 days? *
012345678910
WIth activity over the past 2 days? *
012345678910

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.
Section 1 - Pain Intensity
I have no pain at the momentThe pain is very mild at the momentThe pain is moderate at the momentThe pain is fairly severe at the momentThe pain is very severe at the momentThe pain is the worst imaginable at the moment
Section 2 - Personal Care
I can look after myself normally without causing extra painI can look after myself normally, but it causes extra painIt is painful to look after myself, and I am slow and carefulIt is painful to look after myself, and I am slow and carefulI need some help but manage most of my person careI need help every day in most aspects of self-careI do not get dressed. I wash with difficultly and stay in bed
Section 3 - Lifting
I can lift heavy weights with no extra painI can lift heavy weights, but with extra painPain prevents me from lifting heavy weights off the floor, but I can manage if items are on a tableI can lift only very light weightsI cannot lift or carry anything at all
Section 4 - Work
I can do as much work as I wantI can only do my usual work, but no moreI can do most of my usual workI can't do my usual workI can hardly do any work at all
Section 5 - Headaches
I have no headaches at allI have infrequent slight headachesI have infrequent moderate headachesI have frequent moderate headachesI have frequent severe headachesI have headaches almost all the time
Section 6 - Concentration
I can concentrate fully with difficultyI can concentrate fully with slight difficultyI have a fair degree fo difficulty concentratingI have a lot of difficulty concentratingI have a great deal of difficulty concentratingI can't concentrate at all
Section 7 - Sleeping
I have no trouble sleepingMy sleep is slightly disturbed for less than 1 hourMy sleep is midly disturbed for 1-2 hoursMy sleep is moderately disturbed for 2-3 hoursMy sleep is greatly disturbed for 3-5 hoursMy sleep is completely disturbed for 5-7 hours
Section 8 - Driving
I can drive my car without neck painI can drive as long as I want with slight painI can drive as long as I want with moderate painI can't drive as long as I want because of moderate painI can hardly drive at all because of severe painI can't drive my car at all because of neck pain
Section 9 - Reading
I can read as much as I want with no neck painI can read as much as I want with slight neck painI can read as much as I want with moderate neck painI can't read as much as I want because of moderate neck painI can't read as much as I want because of severe neck painI can't read at all
Section 10 - Recreation
I have no neck pain during all recreational activitiesave some neck pain during all recreational activitiesI have some neck pain with a few recreational activitiesI have some neck pain with most recreational activitiesI can hardly do recreational activities due to neck painI can 't do any recreational activities due to neck pain

Medical Information Release Form

I hearby give permission to Highland Physio Inc. to contact and share or receive health information with my family physician, or any other health professional to determine my progress/and or confirm details of the Auto Insurance payment schedule.
YesNo

Verification

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HIGHLAND PHYSIO INC. PRIVACY POLICY INFORMATION FOR PATIENT

PLEASE READ OUR PRIVACY POLICY INFORMATION FOR PATIENT

Neck Form

ONLY IF WSIB

Medical/Surgical History

Symptoms

P4 Pain Intensity Measure

Neck Disability Index

Medical Information Release Form

Verification

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT