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

EMAIL ADDRESS

example@example.com

DATE OF BIRTH (yyyy/mm/dd)

Date

MAILING ADDRESS (we use email for appointment reminders)

Address

Street Address Line 2

CITY

POSTAL CODE

Home Number

Please enter a valid phone number.Format: (000) 000-0000.

MOBILE NUMBER

Format: (000) 000-0000.

WORK NUMBER

Format: (000) 000-0000.

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

Format: (000) 000-0000.

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)

Date

Signature of Patient/Guardian

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)

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)

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

SEIZURE/EPILEPSY: (no tens/IFC)

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

PREGNANCY OR SUSPECTED:(no modalities)

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

If yes to blood clots, WHERE?

IMPAIRED: CIRCULATION/SENSATION

IMPAIRED: COGNITION (no modalities)

DIABETES: (Treatment can affect blood sugar levels)

RECENT OR SUDDEN WEIGHT LOSS/GAIN

Do You Smoke?

Do you exercise regularly?

HEART: Check all that apply

LUNG: Check all that apply

ALLERGIES: Check all that apply

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

MEDICATIONS: PLEASE CHECK IF YOU ARE TAKING ANY OF THE FOLLOWING:

Other

Are you on any medications to help treat the current condition, if so, do they help?

Fall Checklist

Rows	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?