Patient Intake Form

CONFIDENTIAL PATIENT INFORMATION
Name*
First Last
Date of Birth*

Day
Month
Year
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Phone (w)
Email*

For appointment confirmation
Family Doctor
First Last
Family Doctor's Phone
Referring Practitioner's Name*
First Last
Referring Practitioner's Phone
Is this a motor vehicle accident (MVA) injury?*
- Yes
- No
If yes, please notify the receptionist.
How did you find out about the clinic?*
- Doctor
- Google Search
- Word of Mouth
- Returning Client
- Website
- Walk in/Sign
WORK ENVIRONMENT
Occupation*
Employer's
Work Station Ergonomic Assessment Recommendations
GENERAL HEALTH QUESTIONS
Have you had any illnesses within the last 3 weeks? (i.e., colds, infections)*
- Yes
- No
Have you noticed any lumps or thickening of the skin or muscle anywhere on your body?*
- Yes
- No
Have you had any unexplainable weight loss in the past two months?*
- Yes
- No
Have you ever smoked?*
- Yes
- No
If yes, do you still smoke?
- Yes
- No
Do you have metal implants in your body? (i.e., hip/knee replacement, pacemaker)*
- Yes
- No
Are you taking any prescription or over the counter medication?*
- Yes
- No
If yes, please list
MEDICAL HISTORY
Please check below for any conditions that you are experiencing or have experienced.
Cardiovascular
- High Blood Pressure
- Angina or chest pain
- Heart attack or heart disease
- Stroke
- Pacemaker
- Congestive heart failure
- Anemia
- High cholesterol
- Phlebitis
Respiratory
- Shortness of breath
- Chronic bronchitis
- Asthma
- Pneumothorax
Musculoskeletal
- Fractures
- endonitis/bursitis
- Third Choice
- Ligament sprains
- Muscle strains
- Disc hernias
- Osteoporosis
- Osteoarthritis
- Rheumatoid Arthritis
- Whiplash
Infectious Disease
- HIV/AIDS
- Hepatitis
- Herpes
- Warts/plantar warts
Neurological
- Headaches/migraines
- Multiple Sclerosis
- Parkinson's Disease
- Epilepsy/seizures
- Concussions
Other Conditions
- Cancer
- Diabetes
- Fibromyalgia
- Lupus
- Depression
- Diseases of the eye (glaucoma)
- Sleep disorders
- Fainting
- Disturbances in hearing (tinnitus)
- Skin conditions (eczema, psoriasis)
- Allergies
Gastrointestinal
- Kidney disease
- Colon disease
- Celiac
- Ulcers/Crohn's disease
- Urinary tract infection
- Nausea/vomiting
- Incontinence
Pregnant (due date)
DD slash MM slash YYYY
Recent pregnancy (date)
DD slash MM slash YYYY
Hormonal changes

(fertility treatments, menopause, endometriosis)
Other
Surgeries
(type and date)
Please let your therapist know immediately if any of the above answers change.

We require 24 hours notice if you need to reschedule or cancel your appointment. If the appointment is not cancelled with proper notice, a fee of $38.00 will be charged to your account for a 30-minute appointment; a fee of $50.00 will be charged to your account for a 60-minute appointment.
Consent*
I consent to the assessment of my current problem.
Date of Signature*
DD slash MM slash YYYY
Informed Patient Consent To Care

Prior to assessment and treatment, as a matter of ethics and law, there is an obligation to disclose any material risk to the patient in order to obtain valid informed consent.

The initial assessment contains an examination consisting of: postural analysis, physical examination, muscle testing and orthopedic/neurological examination.

After this initial assessment, examination findings will be interpreted and you will be given an oral report of findings and recommendations as to the rehabilitation treatment required in your particular case. If your condition would be best treated by another health discipline, you will be advised and referred accordingly.

As part of the treatments, certain procedures and devices may be utilized such as the use of heat, ice, electrotherapy, ultrasound, manual therapy and acupuncture. During your rehabilitation program you may be assisted by kinesiologists, physiotherapy assistants or students using certain testing procedures, devices and equipment such as weight machines, exercise, stretching, cardiovascular work and functional tasks. Your practitioners will exercise their professional judgement to do no harm during the course of the procedures, in that your best interest of health is always of primary importance.
Patient consent to care
I understand I will have the opportunity to discuss with my health care provider and/or other clinical staff, the nature and purpose of treatments. I understand that results are not guaranteed.

I further understand and am informed that there are some very slight risks to treatments, including, but not limited to, muscle strain, sprains, disc injuries and bums. I have been made aware that there are remote chances of injury and that appropriate tests will be performed to help identify if I may be susceptible to risk or injury.

By signing below I agree that I am informed of the potential risks and indicate my intention to participate in the course of diagnosis and treatment recommended by the practitioner.
Patient Consent for the Collection, Use and Disclosure of Personal Information

Privacy of your personal information is an important part of Motion Matters Physiotherapy and Sports Injury Clinic, while providing you with quality treatment and care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.

All staff members who come in contact with your personal information are aware of the sensitive nature of the personal information that you have disclosed to us. They are trained in the appropriate use and protection of your information.

Our privacy policy outlines what Motion Matters is doing to ensure that:

•   Only necessary information is collected about you
•   We only share your information with your consent
•   Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols
•   Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Canadian Physiotherapy Association/ the Ontario College of Physiotherapists

How our clinic collects, uses and discloses patient's personal information

Motion Matters understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how Motion Matters is using and disclosing your information. The clinic will collect, use and disclose information about you for the following purposes:

•   To assess your health concerns
•   To provide health care
•   To advise you of treatment options
•   To establish and maintain contact with you
•   To send you newsletters and other mailings
•   To remind you of upcoming appointments
•   To communicate with other treating health care providers
•   To allow us to efficiently follow-up for treatment, care and billing
•   To complete claim forms for insurance purposes
•   To invoice for goods and services
•   To process credit card payments
•   To collect unpaid accounts
•   To comply with all regulatory and legal requirements including court orders, statutory requirements including to advise authorities of child abuse, reportable diseases and individuals who may be an imminent threat to harm themselves or others

Patient consent for collection, use and disclosure of personal information

I have reviewed the above information that explains how Motion Matters Physiotherapy and Sports Injury Clinic will use my personal information, and the steps that Motion Matters is taking to protect my information. I agree that Motion Matters can collect, use and disclose personal information about me as outlined above.
Name*
First Last
Date*
MM slash DD slash YYYY

CONFIDENTIAL PATIENT INFORMATION

WORK ENVIRONMENT

GENERAL HEALTH QUESTIONS

MEDICAL HISTORY

Patient consent to care