Telma Grant Private Pay Direct Billing

HEALTH INTAKE AND HEALTH QUESTIONNAIRE

TEXT AND EMAIL ARE OUR PRIMARY METHOD OF COMMUNICATING WITH PATIENTS. IF POSSIBLE, PLEASE PROVIDE US WITH BOTH YOUR MOBILE AND EMAIL ADDRESS.
Name

FIRST NAMELAST NAME
Middle Name
Preferred Name
EMAIL ADDRESS
example@example.com
DATE OF BIRTH (yyyy/mm/dd)

YearMonthDay
Date
MAILING ADDRESS (we use email for appointment reminders)

Address

Street Address Line 2

CITYState / Province

POSTAL CODE
Home Number
Please enter a valid phone number.
MOBILE NUMBER
WORK NUMBER
EMERGENCY CONTACT: The College of Physiotherapists of Ontario requires that we obtain an emergency contact. Please provide an emergency contact for our records.
FULL NAME
RELATIONSHIP
PHONE NUMBER
Please read carefully. By checking off the box and signing at the bottom you are agree to the following policies

CANCELLATION POLICY:

Patients who do not provide 24 hours notice to cancel an appointment will be charged our full current fee for that appointment.

Late Arrivals: May be accommodated if the schedule allows; otherwise, you will be charged our full current fee for that appointment.

Missed appointments fees are not covered by insurance or OHIP.

PAYMENT POLICY:

Payment is due at the end of every appointment.

Please Note: Clients must keep track of their own insurance coverage limits and are responsible for any charges not covered by insurance. Telma Grant P.T is not responsible for tracking coverage limits.

By indicating and signing below, I hereby authorize Telma Grant, P.T to release reports and/or all or part of my (or my child's) physiotherapy patient record to the following:
My Family Physician
My Specialist
Other
Date (yyyy/mm/dd)

YearMonthDay
Date
Signature of Patient/Guardian

Clear
By signing this document, you are confirming that all information is correct and that you have read and understood our clinic's cancellation and payment policies.
Name

FIRST NAMELAST NAME
DATE OF BIRTH (yyyy/mm/dd)

YearMonthDay
Date
MEDICAL CONTRAINDICATIONS AND HISTORY: IF PATIENT APPLIES TO ANY MEDICAL CONDITION BELOW, PATIENT IS UNABLE TO HAVE ANY OF THE FOLLOWING MODALITIES: TENS/ULTRASOUND
ELECTRONIC IMPLANT/PACEMAKER:(No tens/IFC or shockwave)

YesNo
OPEN WOUNDS, RASHES OR ECZEMA OR PSORIASIS:(no treatment over affected area)

YesNo
SEIZURE/EPILEPSY: (no tens/IFC)

YesNo
CANCER/SKIN CANCER: (ACTIVE TREATMENTS OR WITHIN 3MONTHS) (No tens/IFC, klaser, shockwave, acu)

YesNo
PREGNANCY OR SUSPECTED:(no modalities)

YesNo
BLOOD CLOTS? (DVT) (no treatment over affected area)

YesNo
If yes to blood clots, WHERE?
IMPAIRED: CIRCULATION/SENSATION

YesNo
IMPAIRED: COGNITION (no modalities)

YesNo
DIABETES: (Treatment can affect blood sugar levels)

YesNo
RECENT OR SUDDEN WEIGHT LOSS/GAIN

YesNo
Do You Smoke?

YesNo
Do you exercise regularly?

YesNo
HEART: Check all that apply

Heart PalpitationsAngina (Chest Pain)Abnormal Heart Rate: HighAbnormal Heart Rate: LowBlood Pressure
LUNG: Check all that apply

AsthmaEmphysemaShortness of BreathChronic Lung Problem
ALLERGIES: Check all that apply

Skin TapeBand AidLatexUltrasound GelOther
Do You Have Any Recent Fractures (Last 3 Months)
Have You Had Any Recent Surgeries (Last 3 Months)
Do You Have Any Total Joint Replacements (Knee, Shoulder, Hip):(No Ultrasound over affected area, Tens is fine if intact sensation)
Check all that apply

Abnormal BleedingArthritisDizzinessHard of HearingBowel/Bladder ProblemsOsteoporosisThyroid Problem (hyper or hypo)Auto Immune DisorderHepatitis or HIV (No acu)
MEDICATIONS: PLEASE CHECK IF YOU ARE TAKING ANY OF THE FOLLOWING:

Anticoagulants (blood thinners)Pain PatchOxycontinMuscle RelaxantsBlood Pressure MedicationsMorphinePercocetHeart MedicationDiabetes Medication(insulin)Anti-inflammatoriesSteroids (Cortisone)
Other
Are you on any medications to help treat the current condition, if so, do they help?

YesNo

Fall Checklist

	Yes	No
Experiences dizziness/vertigo with the change of position?
Have you had any falls in the past 12 months?
Do you have a problem with your memory?

If you had any falls in the past 12 months, how many times?
Should be Empty:

HEALTH INTAKE AND HEALTH QUESTIONNAIRE