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Forms – Pelvic Physiotherapy Intake form

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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
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)

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
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.
Referring Physician's NameReferring physicians full name
Referring Physician's PhoneReferring physicians phone no.
Referring Physician
Referred by:Check those that apply
Others (Please specify)Please specify
CONSENT TO ASSESSMENT & TREATMENT
I hereby consent to assessment and/or treatment given by registered physiotherapist(s):

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:
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, wehave adopted the following policy.


If for any reason you have to cancel or re-schedule yourappointment with us, we require that you call or email the clinic 48 hours or 2business days in advance to inform us of the change.  This will allow us to reschedule yourappointment and open the time slot for patients on the waiting list.  A cancellation/no-show fee in the full amountof the booked missed appointment will otherwise be charged.


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
HIV/AIDS
Diabetes
Stroke/CVA
Breathing/Respiratory
Dizziness/Fainting
Digestive
Rheumatoid Arthritis
Cancer
Skin conditions /Bruising
Urogenital /Bruising

Activity Level

Please check all current activities and activity goals appropriately:

Running
Walking
Cycling
Fitness
Yoga
Golf
Swimming
Others
Please specify other activities
Are you currently pregnant?
How many weeks
Due Date
Do you have any other children?

Allergies (Please check all boxes that apply to you)

Latex
Vinyl
Silicone
Gel
Coconut Oil
Other Allergies
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
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