Pre-assessment Back Form - Highland Physio

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 *

OHIP Number

Social Insurance Number

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/Pelvic

Please give an appropriate date of onset of each condition you've selected

Please check if you have ever had any of the following symptoms.Joint 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? *

YesNoOption 3

If yes please describe, and include dates (month, year)

Please list any medications you currently taking (including Advil, Tylenol, ibuprofen, etc.)

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

When your back hurts, you may find it difficult to do some of the things you normally do. Check only the sentences that describe you today

I stay at home most of the time because of my backI change position frequently to try to get my back comfortableI walk more slowly than usual because of my backBecause of my back, I am not doing any job that I usually do around the houseBecause of my back, I use a handrail to get upstairsBecause of my back, I lie down to rest more oftenBecause of my back, I try to get other people to do things for meI get dressed more slowly than usual because of my backI only stand up for short periods of time because of my backBecause of my back, I try not to bend or kneel downI find it difficult to get out of a chair because of my backMy back is painful most of the timeI have trouble putting on my socks because of the pain in my backI can only walk short distances because of my backI sleep less well because of my backBecause of my back pain, I get dressed with the help of someone elseI sit down for most of the day because of my backI avoid heavy jobs around the house because of my backBecause of back pain, I am more irritable and bad tempered with people than usualBecause of my back, I go upstairs more slowly than usualI stay in bed most of the time because of my back

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

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT

PLEASE READ OUR PRIVACY POLICY INFORMATION FOR PATIENT

Back Form

ONLY IF WSIB

Medical/Surgical History

Symptoms

P4 Pain Intensity Measure

The Roland-Morris Low Back Pain and Disability Questionnaire

Medical Information Release Form

Verification

HIGHLAND PHYSIO INC. PRIVACY POLICY INFORMATION FOR PATIENT

PLEASE READ OUR PRIVACY POLICY INFORMATION FOR PATIENT

Back Form

ONLY IF WSIB

Medical/Surgical History

Symptoms

P4 Pain Intensity Measure

The Roland-Morris Low Back Pain and Disability Questionnaire

Medical Information Release Form

Verification

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT