Midhurstphysio

MIDHURST WELLNESS CENTRE: MAPLEVIEW PHYSIOTHERAPY: CONFIDENTIAL MEDICAL INFORMATION
DATE

MonthDayYear
Date
NAME
Address

ADDRESS

Street Address Line 2

CITYState / Province

POSTAL CODE
DATE OF BIRTH

YearMonthDay
Date
PRIMARY PHONE no.
Check:

CellHomeWork
EMAIL ADDRESS or ALTERNATE PHONE no.
INJURY/AREA TO BE TREATED:
Motor Vehicle Accident Claim

MonthDayYear
date of accident
WSIB Claim

MonthDayYear
date of injury
EXTENDED HEALTH CARE COVERAGE THROUGH MY PLAN:

YESNO
EXTENDED HEALTH CARE COVERAGE THROUGH MY SPOUSE OR OTHER:

YESNO
I am aware that if I qualify for online billing, I am still responsible to keep track of treatment costs and how much coverage is available from my plan. I am responsible for any treatment costs not covered by my plan.
Initial
I WAS REFERRED BY:

DOCTORFRIEND/FAMILYI AM A REPEAT PATIENTWALK-INYELLOWPAGES.CAYELLOWPAGES PHONEBOOKGOOGLEADVERTISEMENTOther
FAMILY PHYSICIAN
CITY
REFERRING PHYSICIAN
CITY
I, undersigned, herewith consent to treatment for above-mentioned condition(s), and to the communication between the treating professionals at this clinic and/or Physicians or other Health Care Professionals.

I am aware that there is a 24 hour cancellation policy and may be charged for a missed appointment.
Signature

Clear
GENERAL HEALTH QUESTONNAIRE

Questionnaire

	YES	NO
Are you on medications?
Do you have high/low blood pressure
Do you have any form of heart problems
Do you have any form of thyroid problems
Do you smoke?
Have you been diagnosed with arthritis
Do you have diabetes
Do you have or ever had cancer
Have you ever broken a bone
Do you have any metal fixations, plates, screws etc.
Do you have any abdominal problems, i.e. hernia, ulcer
Have you had any previous surgeries:
Are you, or could you be pregnant if female
Have you been involved in a previous car accident
Do you have any allergies, skin irritations, infections etc.
Do you have asthma or any respiratory problems
Do you have any other health problems not listed above

Are you on medications? If YES, please list:
Do you smoke? How many?
Have you had any previous surgeries: (please list)
Have you been involved in a previous car accident (if YES, Date:)

MonthDayYear
Date
Do you have any other health problems not listed above?
Emergency contact person
Phone No.
Client Signature

Clear
Should be Empty:

MIDHURST WELLNESS CENTRE: MAPLEVIEW PHYSIOTHERAPY: CONFIDENTIAL MEDICAL INFORMATION