Forms - Pelvic Physiotherapy Intake form

PELVIC HEALTH INTAKE FORM

FORM #: 1023

PATIENT INFORMATION

Patient ID: _________________

Your Last NameYour Last Name

Your First NameYour First Name

Your Date of BirthYour date of birth

Gender

MaleFemale

Your Address (Street & number)Street and number

Your City

ProvinceClick to pick a province

Postal Code

Home Phoneyour home phone

Work Phoneyour work phone

Cell Phonefor phone & text reminders

Physiomobility Health Group staff may leave phone messages at provided numbers for confirmation or changes to your scheduled appointments. (Please check the phone numbers below if you do not want us to leave phone messages)

Your Email Addressvalid email

By providing your email, you are consenting to email communication from Physiomobility Health Group such as appointment reminders, statements, invoices, exercise instructions, newsletters & commercial electronic messages.

Do not leave phone messages on these phone numbers:Chcek those that apply

Home PhoneWork PhoneCell Phone

EMERGENCY CONTACT INFORMATION

Emergency contact’s Last NameEmergency contact’s Last name

Emergency contact’s First NameEmergency contact’s First name

RelationshipRelationship to your emergency contact

Emergency contact’s Phone No.Emergency contact’s Phone no.

FAMILY PHYSICIAN INFORMATION

Physician’s Full Namefamily physicians full name

Physician’s Phone No.family physicians phone no.

REFERRAL INFORMATION

Referring physicianCheck this if your are referred by your Family physician above otherwise enter physician’s name and phone number below.

Same as above

Referring Physician’s NameReferring physicians full name

Referring Physician’s PhoneReferring physicians phone no.

Referring Physician

OB/GYNMidwifeUrologist

Referred by:Check those that apply

Doctor (check only if you have been referred to Physiomobility by your doctor)InternetSocial mediaEventsStaffWork/Live in Shops at Don MillsPelvic Solutions websiteOthers

Others (Please specify)Please specify

If you are referred by Family, Friend or a Patient, who should we thank:

Name of the friend, family or Patient

CONSENT TO ASSESSMENT & TREATMENT

I hereby consent to assessment and/or treatment given by registered physiotherapist(s):

Kanako NishiharaMihaela MaricaArmina Tehrani

I understand that my treatments may include treatments for therapeutic, preventative, diagnostic and/or other health related purposes. I understand that I may rescind my consent at any time.

PELVIC HEALTH CONSENT: I understand that an internal assessment of the functioning of my pelvic floor may be deemed appropriate and there may bean internal component (vaginal/rectal) to the assessment and/or treatments. When this is the case, this will be discussed in detail with me before proceeding and I may grant or refuse consent.

Please read carefully and check the followings:

I consent to have assessment and follow up communications sent to my healthcare providers.I have read the above consent and have had an opportunity to ask questions about its contents.

CANCELLATION or NO SHOW POLICY

We, at Physiomobility are here to provide you with thevery best care and attention. Weunderstand that unforeseen events and emergencies occur in everyone’s lives. Last minute cancellations and no-shows affectour ability to provide an outstanding experience to all of our patients.

In consideration for our therapists’ time, we have adopted the following policy:

We require a minimum of 24 hours’ notice for change or cancellation of any appointment. This will allow us to fill the available time slot with another patient who needs our services. A full amount of the service fee will be charged for late cancellation/no show if you cancel the same day or if you do not show up for your appointment. Please note that this fee is not billable to insurance policy and remains your responsibility.

For your information, our payment processing system saves an encrypted version of the credit or debit card ,similar to the practice of many other clinics. This information is stored on the merchant processing system, not within our system. Only the last 4 digits of the card are visible to our staff. We do reserve the right to keep a credit card on file for the purpose of charging balances, no show fees or late cancellation fees.

SIGN & SUBMIT

Electronic Signature

Please write Patient/Guardian full name below which serves as electronic signature.

Patient/ Guardian nameyour full name

Dateof appointment

CONFIDENTIAL HEALTH PROFILE

Primary reason for Consultation:

Please write here your primary reason for Consultation

Please check all boxes that apply to you:

Heart/Circulatory

YesNo

HIV/AIDS

YesNo

Diabetes

YesNo

Stroke/CVA

YesNo

Breathing/Respiratory

YesNo

Dizziness/Fainting

YesNo

Digestive

YesNo

Rheumatoid Arthritis

YesNo

Cancer

YesNo

Skin conditions /Bruising

YesNo

Urogenital /Bruising

ProstatitisInterstitial CystitisUTIsVaginismusPelvic organ prolapseVulvodyniaUrinary incontinence

Activity Level

Please check all current activities and activity goals appropriately:

Running

CurrentGoal

Walking

CurrentGoal

Cycling

CurrentGoal

Fitness

CurrentGoal

Yoga

CurrentGoal

Golf

CurrentGoal

Swimming

CurrentGoal

Others

Other activities

Please specify other activities

Are you currently pregnant?

YesNo

How many weeks

Due Date

Do you have any other children?

YesNo

Allergies (Please check all boxes that apply to you)

Latex

YesNo

Vinyl

YesNo

Silicone

YesNo

Gel

YesNo

Coconut Oil

YesNo

Other Allergies

YesNo

List Other Allergiesyour full name

Medications/Creams (Please list below)

1. Medication/Creamyour full name

2. Medication/Cream

3. Medication/Cream

4. Medication/Cream

5. Medication/Cream

6. Medication/Cream