Joint Physio Information Sheet

INFORMATION SHEET
Date

MonthDayYear
Date
Name
Date of Birth

MonthDayYear
Date
Occupation
Best Phone #
Format: (000) 000-0000.
Family Physician
MEDICAL HISTORY

Please check the boxes for any condition(s) you have had or are currently experiencing.
CARDIOVASCULAR

High Blood PressureLow Blood PressureHeart AttackAnginaHeart DiseaseStrokeOther
RESPIRATORY

Shortness of BreathAsthmaEmphysemaBronchitisPneumoniaTuberculosisOther
CANCER

Yes
Onset/Type/Current State
BONE HEALTH

ArthritisOsteoporosis/OsteopeniaOther
DIABETES

Yes
Onset/Type
NEUROLOGICAL

Multiple SclerosisEpilepsyPolioOther
BLOOD RELATED

AnemiaHemophiliaHepatitisHIV/AIDSOther
PREGNANCY

Yes I am currently pregnantThere is a possibility I am pregnant
Due Date

MonthDayYear
Date
LATEX INTOLERANCE

Yes
OTHER CONDITION(S)

MigrainesAllergiesMental HealthDigestive ConditionsThyroidOrgan DysfunctionOther
Allergies:
Mental Health:
Digestive Conditions:
Thyroid:
Organ Dysfunction:

Please circle the appropriate response and provide more information as required.

Rows	Yes	No
Are you taking any prescription or over-the-counter medications?
Have you previously had surgery?
Have you recently had any unexplained weight gain or loss?
Are you on a special diet prescribed by a physician?
Have you noticed any changes to your skin or muscle anywhere on your body (ie.lumps, unhealed sores, changes in size, shape or colour of a wart or mole)?
Do you smoke or chew tobacco?
Do you consume alcohol and/or caffeine (including soft drinks, coffee, tea or chocolate)?
Are you currently attending treatment with any other healthcare providers (Chiropractor, Massage Therapist, Osteopath, Occupational Therapist, Speech Therapist, etc.)
Do you have a history of falls?

If yes, please list and what they are for:
If yes, please list details/hardware (ie. pacemaker, metal implants, joint replacements, transplanted organ):
Are you on a special diet prescribed by a physician? If yes, please describe:
Have you noticed any changes to your skin or muscle anywhere on your body (ie.lumps, unhealed sores, changes in size, shape or colour of a wart or mole)? If yes, please describe:
If yes, how many packs/day and for how long?
If yes, please provide details on how much you consume daily/weekly:
If yes, please provide more information:
If yes, please provide more information regarding frequency, onset, injuries sustained, etc.:
FINANCIAL RESPONSIBILITY
I am aware that Joint Physiotherapy does not have OHIP Billing Privileges. I am responsible for payment of all fees for goods and services received. These fees are due at time of service, and include Initial Assessment Fees, Treatment Fees, Report Fees, Missed Appointment Fees and sale of goods/products. A current fee schedule is readily available at our front desk. Private fees are based per session of care. This clinic accepts cash, debit and cheque.
Signature

Clear
Date

MonthDayYear
Date
NO SHOW/CANCELLATION POLICY
Your appointment time has been reserved specifically for you. We appreciate 24 hours advance notice for any cancellations and reserve the right to charge a no show/cancellation fee if not adhered to.
Signature

Clear
Date

MonthDayYear
Date
CONSENT TO ASSESSMENT
I hereby consent to a physiotherapy assessment. My consent can be withdrawn at any time.
Signature

Clear
Date

MonthDayYear
Date
PERSONAL INFORMATION
Protecting your privacy and personal information is an important part of Joint Physiotherapy’s policies and procedures. Joint Physiotherapy collects, uses, discloses, retains and disposes of your personal information in compliance with federal and provincial legislation and applicable college regulations.

How Our Office Uses, Collects and Discloses Personal Information
- To schedule appointments
- To assess your health concern/condition, advise you of options and provide care
- To obtain diagnostic test results pertinent to the condition for which you are seeking treatment
- To enable us to establish and maintain contact and communicate with you regarding your care
- To direct emergency needs to the appropriate individual
- To communicate with other healthcare providers involved in your care including but not limited to your physician
- To invoice for goods and services
- To collect unpaid accounts and process payment
- To follow-up with clients regarding continuity of care
- To comply with all applicable legal and regulatory requirements in providing Physiotherapy services (ie. Regulated Health Professions Act, College of Physiotherapists of Ontario, Canada Customs and Revenue Agency, Information and Privacy Commissioner, Human Rights Commission)
- To complete claims for insurance purposes
- To complete additional paperwork as requested
By initialing/signing the consent sections of this form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. You may withdraw this consent at any time.

The cost of some goods/services provided by Joint Physiotherapy to clients is indirectly paid for by third parties (ie. Extended Health Benefits, Government Funding). These third party payers often have your consent or legislative authority to direct us to collect and disclose to them certain information in order to confirm client entitlement to this funding (ie. confirmation and details related to client attendance).
I give Joint Physiotherapy my consent to release/obtain information as necessary to confirm entitlement.
Initials
I give Joint Physiotherapy my consent to release/obtain information to/from my physician/specialist with respect to my care.
Initials
I give Joint Physiotherapy my consent to release/obtain information to/from my emergency contact to facilitate my care.
Initials
I give Joint Physiotherapy my consent to release/obtain information to/from the following individual to facilitate my care (eg. sibling, adult child, parent, other healthcare providers not previously listed Other:
Other
I give Joint Physiotherapy my consent to release/obtain information to/from the following individual to facilitate my care (eg. sibling, adult child, parent, other healthcare providers not previously listed).
Initials
I have reviewed the above information that explains how Joint Physiotherapy will use my personal information, and the steps the clinic is taking to protect my information. I agree that Joint Physiotherapy can collect, use and disclose personal information as set out above in the information about the office’s privacy policies.
Name (print)
Signature

Clear
Date

MonthDayYear
Date
Witness
If you have any questions regarding how your personal information will be collected, used, disclosed, retained or disposed of, please do not hesitate to ask to speak to our Privacy Officer.
Should be Empty:

INFORMATION SHEET

MEDICAL HISTORY

FINANCIAL RESPONSIBILITY

NO SHOW/CANCELLATION POLICY

CONSENT TO ASSESSMENT

PERSONAL INFORMATION