Pre-Assessment Forms - 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 DisordersPace MakerProstrate/Pelvic

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

Please check if you 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.)

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

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

General Form

ONLY IF WSIB

Medical/Surgical History

Symptoms

P4 Pain Intensity Measure

Medical Information Release Form

Verification

HIGHLAND PHYSIO INC. PRIVACY POLICY INFORMATION FOR PATIENT

PLEASE READ OUR PRIVACY POLICY INFORMATION FOR PATIENT

General Form

ONLY IF WSIB

Medical/Surgical History

Symptoms

P4 Pain Intensity Measure

Medical Information Release Form

Verification

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT