HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT

PLEASE READ OUR PRIVACY POLICY INFORMATION FOR PATIENT

Lower Body 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/Pelvic
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 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? *
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

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:
Any of your usual work, housework, or school activities
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Your usual hobbies, recreational or sporting activities
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Getting into or out of the bath
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Wa lking between rooms
Extreme Difficulty or Inability to PerformQuite a bit of DiffcultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Putting on your shoes or socks
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Squatting
Extreme Difficulty or Inability to PerformQuit a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Lifting an object from the floor
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Performing light activities around your home
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Performing heavy activities around your home
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle Bit of DifficultyNo Difficulty
Getting into or out of a car
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Walking around the block
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Walking a mile
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Going up or down 10 stairs
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNoDifficulty
Standing for one hour
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Running on even ground
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Running on uneven ground
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Making sharp turns while running fast
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Hopping
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty
Rolling over in bed
Extreme Difficulty or Inability to PerformQuite a bit of DifficultyModerate DifficultyLittle bit of DifficultyNo Difficulty

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

Lower Body Form

ONLY IF WSIB

Medical/Surgical History

Symptoms

P4 Pain Intensity Measure

Lower Extremity Functional Scale

Medical Information Release Form

Verification

HIGHLAND PHYSIO INC.
PRIVACY POLICY INFORMATION FOR PATIENT