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.
Format: (000) 000-0000.
Check:
EMAIL ADDRESS or ALTERNATE PHONE no.
INJURY/AREA TO BE TREATED:
Have you, or are you seeing a health care professional for this injury?
Preferred Pronouns
Accessibility Needs
Do you have extended healthcare coverage?
Were these injuries sustained at work, or as result of a motor vehicle collision?
If I qualify for online billing, I understand that I am responsible to keep track of treatment costs and how much coverageis available in my plan. I understand that I am responsible for any treatment costs not covered by my plan.
Initial
I was referred to Midhurst Wellness Centre by

Other
FAMILY PHYSICIAN
CITY
EMERGENCY CONTACT
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I, undersigned, 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

Rows	YES	NO
Are you on medications?
Do you have high blood pressure
Do you have low blood pressure
Do you have any heart conditions?
Do you have any thyroid conditions?
Do you have any neurological conditions? ie.: epilepsy, MS,Parkinson’s…
Have you been diagnosed with arthritis?
Do you have diabetes?
Do you, or have you 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 surgical procedures not already listed?
Are you, or could you be pregnant?
Have you been involved in a previous car accident?
Do you have any allergies, skin irritations, infections etc.?
Do you smoke?
Do you have asthma or any respiratory conditions?
Do you have any other health conditions not listed above?

Are you on medications? If YES, please list (or bring list) :
If cancer was selected above, What, if any, treatment have you received? ie.: surgery,radiation, chemo
Do you smoke? How many____/DAY?
Please list surgical procedures if selected above
Have you been involved in a previous car accident (if YES, Date:)

MonthDayYear
Date
Do you have any other health problems not listed above?
Client Signature

Clear
Should be Empty:

MIDHURST WELLNESS CENTRE: MAPLEVIEW PHYSIOTHERAPY: CONFIDENTIAL MEDICAL INFORMATION