Name

First Name

Last Name

Date of Birth

(dd/mm/yyyy)

Email Address

Reason for visit/Area of injury

Provide description of injury including symptom location, date of appearance (approximate if uncertain) and progression of symptoms since the onset (worse, better or unchanged)

Skin Conditions

Rashes

Bruise Easily

Infectious Skin Condition

Contagious Skin Condition

Skin Allergy

Other

No skin conditions

Head/Neck

Visual impairment

Hearing impairment

Hearing aid

Speech impairment

Sinus problems

Jaw pain (TMJ pain)

Headache/migraine

Other

None of the above

Respiratory

Asthma

Bronchitis

Chronic cough

Emphysema

Difficult breathing

Shortness of breath

Smoking

Other

No respiratory conditions

Infectious Conditions

Herpes / STDs

Tuberculosis (TB)

Hepatitis

HIV / AIDS

Other

No infectious disease

Past surgeries, fractures or accidents

Description and date of incidence

Pregnant?

Enter due date

Medication

Please list all medications, natural remedies, supplements, etc.

Work

Provide work description and additional information if necessary (ex: computer, heavy lifting, standing, frequent forward bending)

Activities of Daily Living

Description of sports, leisure and/or social activities

INFORMED CONSENT TO PHYSIOTHERAPY TREATMENT and RELEASE OF INFORMATION

I, the undersigned, voluntarily consent to the physiotherapist (“PT”) and Lalonde Physiotherapy (the “Clinic”) providing physiotherapy services (the “Treatment”) to me, now and on an ongoing basis, with such Treatment to be within the scope of the PT practice as defined by the College of Physiotherapists of Ontario, including without limitation, such assessments, examinations and techniques, as recommended by the PT. I consent to the PT undraping areas of my body to the extent needed to provide Treatment while considering my comfort, security, and privacy as requested by me. I understand that at any time I may withdraw my consent to Treatment by informing the PT with words to that effect, and then Treatment will be stopped.

POSSIBLE RISKS

I agree that my consent is given while informed of the fact that possible risks to me exist during the course of Treatment.

DUTY TO DISCLOSE MEDICAL HISTORY

I agree that I have a duty to fully disclose to the PT and Clinic all medical conditions affecting me, whether or not I believe any medical condition is applicable or relevant to my Treatment. I further agree that it is my responsibility to keep the PT updated and informed of my medical condition. I declare that the information I have provided in the above Medical History Form is true, accurate and complete.

DISCLOSURE OF PERSONAL INFORMATION

I understand that it may be desirable from time to time for the PT and Clinic to coordinate my health care with others, including but not limited to other Clinic staff, physicians, other health care providers, case managers, and insurance claim adjusters (“Other Providers”), which results in disclosing my personal information (as defined in the Personal Information Protection Act (the “Act”). I consent to the PT and Clinic disclosing my personal information to Other Providers, when done in accordance with the Act. I consent to the shared access between the PT and the Clinic staff to my personal information. I agree that I must expressly withdraw consent of the disclosure of my personal information by providing 2- business day notice of such withdrawal of consent in writing to the PT and Clinic.

CANCELLATION NOTICE

Your appointment time is held for you. Please understand that a missed appointment or late cancellation disables another client from accessing our services. A 24-hr notice would be appreciated.