Patient Information

Type Appointment Note

Name

Date Of Birth

Phone (Home)

Phone (Work)

Doctor Name

Occupation

Address

Allergies

Phone *

Email

Emergency Contact Number

Health Care Number

Reason you are seeking Physiotherapy?

How long has condition existed?

In general, how is your health?

Referred for Physiotherapy by    Doctor     Others

Other Text

Have you had Physiotherapy in the past?    Yes     No

Current Medications

Current Medication Name

Current Medication Condition

Other medical conditions to note

Other medical conditions to note (ie. pins, wires, plates, artificial joints, canes..)

Injuries

Type

Date

Surgeries

Type

Date

Are you currently receiving treatment from another health care professional?

1.Do you have any heart problems?:     Yes     No

2.Do you have any thyroid problems?:     Yes     No

3.Do you have HIGH or LOW blood pressure?:     Yes     No

4.Are you currently taking any medications? :    Yes     No

5.Have you been diagnosed with arthritis?:     Yes     No

6.Do you have diabetes?:     Yes     No

7.Do you have or ever had cancer?:     Yes     No

8.Have you ever broken a bone?:    Yes     No

9.Do you have any metal fixations, plates, screws, etc.?:     Yes     No

10.Do you smoke? :     Yes     No

11.Do you have any abdominal problems, ie hernia, ulcer?:     Yes     No

12.Have you had any previous surgeries :     Yes     No

13.If female, are you or could you be pregnant?:    Yes     No

14.Have you been involved in a previous car accident?:     Yes     No

15.Do you have any allergies, skin irritations, infections, etc?:     Yes     No

16.Do you have asthma or any respiratory problems?:    Yes     No

17.Do you have any other health problems not listed above?:     Yes     No

18.Is there any other reason that you should not do physical activities?:     Yes     No

Last Physiotherapy visit?

Emergency contact person

Emergency Phone

Client’s Signature