Physiotherapy Intake Form

Name

First NameLast Name

Date of Birth

Date

Marital Status

Sex

MaleFemale

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail

Occupation

Name

First NameLast Name

Phone Number

Area CodePhone Number

Relationship

Referring Physician

First NameLast Name

Physician's Phone Number

Area CodePhone Number

Primary Care Physician Name

First NameLast Name

Name of Insurance Company

Policy #

Reason for your visit

Indicate the nature of your pain and symptoms

What makes your condition worse?

What makes your condition better?

How often do you experience the pain/symptoms?

Have you had any imaging performed? (Ultrasound, MRI, etc.)

YesNo

If yes, please indicate findings (scan or copy may be provided instead)

Are your symptoms related to a work injury?

YesNo

Or a motor vehicle accident?

YesNo

Have you had any of the following signs/symptoms?

Cardiovascular

Neurological

Parkinson’s diseaseStrokeMultiple SclerosisOther

Respiratory

Communicable diseases

Metabolic system

Do you have osteoporosis?

YesNo

Have you ever fractured a bone?

YesNo

If yes, please describe:

Do you have arthritis?

YesNo

If yes, please state location/type:

Do you have a history of cancer?

YesNo

If yes, please state onset/type:

Current medications list (scan or copy may be provided instead)

Please list any past surgical history and details (dates/hardware/etc.):

I hereby authorize AgeWell Physiotherapy to gather all the necessary details needed for my appointment to ensure the safety of both the patient and the therapist.
I agree to participate in assessments and treatments given by the physiotherapist. I acknowledge that my treatment provider has given me information that is pertinent to my assessment and treatment, including the possible risks and side effects of the proposed treatment.
Personal information that AgeWell Physiotherapy collect, retain, use and disclose may include without limitation, your age, contact information, personal health information, medical history and other information deemed necessary to fulfill the following purposes:

1. To provide assessment and treatment services.

2. To provide/obtain to/from Third Party Payers, Physicians and Legal Counsel with/from progress reports, assessment findings, diagnostic tests/medical investigations, resulting from the services provided to you or in order to optimize the treatment to be provided to you.

3. To contact you about services you have received or are upcoming.
I agree that I have been informed of the costs of the assessment and the treatments/services provided to me. Fees: Evaluation: 120$, Treatment (1 hr): 120$; Telehealth (1 hr): 100$
I agree that I have been informed of AgeWell Physiotherapy's cancellation policy. All appointments cancelled without 24 hours notice will be charged an 80$ fee.

Name & signature of patient/legally responsible person

Reason why patient is unable to sign

Date Signed

Date

Physiotherapy Intake Form

Personal Information

Emergency Contact

Insurance Information

Current Symptoms

Medical History

Authorization/Consent