Physiotherapy Intake Form

Name

First Name Last Name
Contact Information

Email (example@example.com) Phone Number
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Date of Birth

Age

Day (DD)

Month (MM) Gender

Year (YYYY)
Height and Weight

Height Weight
Occupation:
Family Physician

Family Physician Name

Family Physician Address
How did you hear about us?
Extended Health Benefits
Do you have health insurance?

Yes No
Does your spouse have health insurance?

Yes No
Spousal Date of Birth

Day (DD)

Month (MM)

Year (YYYY)
Health Insurance Information

Insurance Provider

Plan/Policy Number

Member ID
Sign Here:

Clear
Please indicate where the pain is located
Front of Body - Right Side

Forehead Collarbone Chest Bicep Elbow Wrist Hand Hip Thigh Knee Shin Ankle Foot
Front of Body - Left Side

Forehead Collarbone Chest Bicep Elbow Wrist Hand Hip Thigh Knee Shin Ankle Foot
Side of Body - Right Side

TMJ Neck Shoulder Ribs Hip Thigh Knee Calf Ankle Foot
Side of Body - Left Side

TMJ Neck Shoulder Ribs Hip Thigh Knee Calf Ankle Foot
Back of Body - Right Side

Head Neck Shoulder Triceps Wrist Hand Mid back Lower back Glutes Hamstring Knee Calf Heel
Back of Body - Left Side

Head Neck Shoulder Triceps Wrist Hand Mid back Lower back Glutes Hamstring Knee Calf Heel
When did this pain begin?
Was this pain from a:

Work Injury Auto Accident
Is the pain getting:

Better Worse
Does this pain occur:

All Day Comes & Goes
Do you experience pain when you cough?

Yes No
What is the quality of pain?

Sharp Dull Achy Stabbing Shooting
Severity of Pain:

0 (no pain) 1 2 3 4 5 6 7 8 9 10 (severe)
When is the pain better?

Morning Afternoon Evening Night All Day
When is the pain worse?

Morning Afternoon Evening Night All Day
Does the pain travel to any other parts of the body?

Yes No
Are you experiencing numbness or tingling sensations?

Yes No
What makes the pain better?
What makes the pain worse?
Who have you seen for this condition?

Family Doctor Chiropractor Massage Therapist Physiotherapist Acupuncturist Chiropodist Specialist Other
Do you or your immediate family have any of the following conditions?

Cancer Diabetes Heart Disease Arthritis Osteoporosis High BP Stroke
Are you on any medication?

Yes No
Have you been diagnosed with any medical conditions?

Yes No
Have you had any surgeries?

Yes No
Have you fractured or dislocated any bones?

Yes No
Have you had a physical exam over the past 12 months?

Yes No
Have you been in an auto accident in the past 2 years?

Yes No
Have you been admitted to a hospital before?

Yes No
Have you had any major slips or falls?

Yes No
Are you experiencing any muscle weakness?

Yes No
Have you experienced any abnormal gain or loss in weight recently?

Yes No
Does the pain wake you up at night?

Yes No
Are you experiencing night sweats?

Yes No
Are you experiencing any swelling?

Yes No
Has the pain prevented you from working?

Yes No
Have you had this condition previously?

Yes No
Do you play any contact sports (i.e. football, hockey)?

Yes No
Do you have a family history of this condition?

Yes No
Have you had X-rays in the past five years?

Yes No
Have you had a MRI in the past five years?

Yes No
Have you been prescribed orthotics?

Yes No
Are you a smoker?

Yes No
Are you physically active?

Yes No
(Women Only) Are your pregnant?

Yes No
Please rate your average stress level:

0 (No Stress) 1 2 3 4 5 6 7 8 9 10 (Severe)
To what extent has this condition affected your daily life?

0 (None) 1 2 3 4 5 6 7 8 9 10 (Severely)
How motivated are you towards treatment of your pain condition?

0 (Not Motivated) 1 2 3 4 5 6 7 8 9 10 (Considerably Motivated)
Electronic Transmission Authorization and Consent Form

Instructions: This form must be filled out when claims are submitted electronically by the provider on the patient’s behalf. Please retain this form in the patient’s file for verification purposes for two years following closure of the patient file.

Provider: Canadian Muscle and Joint Pain Clinic Inc. 4-5980 Churchill Meadows Blvd, Mississauga L5M 7M5
Patient Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Plan and Certificate Number

Plan Number Certificate/Member ID
Consent to Collect and Exchange Personal Information

Message to the Plan member, Spouse and/or Dependent regarding Personal Information

Personal information that we collect and disclose about you, and if applicable, your spouse and/or dependents, is used by the insurer and/or plan administrator and their service provider(s) for the purposes of assessing your claims, underwriting, investigating, auditing and administering the group benefits plan, including the investigation of fraud and/or plan abuse.
Authorization and Consent
I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. I authorize the insurer and / or plan administrator and their service provider(s) to:
- use my personal information for the above purposes.
- exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits or other benefits programs when relevant for the above purposes.
- exchange personal information concerning any claims submitted with the plan member or a person acting on behalf of the plan member.
- exchange personal information for the above purposes electronically or in any other manner. I understand that personal information may be subject to disclosure to those authorized under applicable law. I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.
Additional Consent Applicable to Plan Members Only
I confirm that I am authorized by my spouse and/or dependents, if any, to disclose personal information about them to the insurer and/or plan administrator and their service provider(s) for the purposes described above and I confirm that my spouse and/or dependents also authorize the insurer and/or plan administrator and their service provider(s) to disclose information about their claims to me, for the purposes of assessing and paying a benefit, if any, and managing the group benefits plan. I also authorize my spouse and/or dependents to assign benefit payments under the plan to the healthcare provider. In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my Plan Sponsor, for the purposes of investigation and prevention of fraud and/or plan abuse. If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my Plan Sponsor, for that purpose.
Name

First Name Last Name
Date:

Day Month Year
Date
Signature:

Clear
YOUR PRIVACY IS OUR PRIORITY
Patient Consent Form For Collection, Use and Disclosure of Personal Information
In this office, for their respective patients, Dr. Faisal Malik acts as the Privacy Information Officer. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information. Attached to this consent form, we have outlined what our office is doing to ensure that: Only necessary information is collected about you; Information is shared only with your consent; Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; Our privacy protocols comply not only with privacy legislation, but with the standards of the Ontario Chiropractic Association, and the law. Do not hesitate to discuss our policies with Dr. Faisal Malik or any member of our office staff. Please be assured that every staff member in our office is committed to ensuring that you receive the best quality health care. This office will collect, use and disclose information about you for the following purposes: To offer and provide treatment, care and services for all chiropractic health care issues. To deliver safe and efficient patient health care and to identify and ensure continuous high quality service. To assess your health care needs and to advise you of treatment options. To enable us to contact you and maintain communication with you, for purposes of distributing health care information and booking/confirming appointments for treatments. To maintain communication with you through email newsletters. To invoice for goods and services, to process credit card payments, and to collect on unpaid accounts. To communicate with other treating health care providers, including your pharmacist/pharmacy. To communicate with laboratories in cases where laboratory services are required. For teaching and demonstrating purposes on an anonymous basis. To complete and submit chiropractic claims for third party adjudication and payment. To comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Ontario Chiropractic Association in a timely fashion, when required, according to the provisions of the Personal Health Information Protection Act (PHIPA) . To comply with agreements/ undertakings entered into voluntarily by the member with the Ontario Chiropractic Association, including the delivery and/or review of patients’ charts and records to the Association in a timely fashion for regulatory and monitoring purposes. To deliver your charts and records to the Chiropractic insurance carrier to enable the insurance company to assess liability and quantify damages, if any. To assist this office to comply with all regulatory requirements and to comply generally with the law By signing the consent section of the Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Personal Health Information Protection Act (PHIPA) for the purposes of the Ontario Chiropractic Association fulfilling its mandate under the PHIPA, and for the defence of a legal issue. Our office will not, under any condition, supply your insurer with your confidential medical history. In the event that this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information at any time, and we will explain the ramifications of the decision, and the process.
Patient Consent
I have reviewed the Privacy Policy that explains how this office will use my personal information, and the steps this office is taking to protect my information. I know that this office has a Privacy Policy, and I can ask to see the Policy at any time. I agree that Dr. Faisal Malik and his staff can collect, use and disclose personal information about myself as set out in the attached information about the office’s privacy policies.
Signature:

Clear
Date (DD/MM/YYYY):

Day Month Year
Date
Physiotherapy Informed Consent Form
Consent to assessment and treatment:

Physiotherapy treatment techniques recommended to you may include, but are not limited to: manual techniques, spinal manipulation, therapeutic exercise, hydrotherapy, electrotherapeutic modalities, as well as other techniques and procedures your treating physiotherapist determines may improve your function. Your physiotherapist will explain the benefits, side effects and potential complications of each chosen technique before use. Throughout your recovery program, any questions or concerns you may have about any recommended treatment must be shared with your physiotherapist immediately so they can explain the treatment rationale and/ or modify your program appropriately. If at any time you choose not to participate in the course of treatment, please tell your physiotherapist immediately.

I hereby freely consent to participate in the physical and functional assessment and recommended treatment program (based on my medical history, diagnosis, symptoms and assessment results) delivered by those authorized in this clinic, having been informed about the following:
- What to expect in the assessment and treatment
- Who will be performing the assessment and treatment
- The reasons why I should have the assessment/treatment
- Consequences of not having the assessment/treatment
- Any potential risks and/or side effects for the assessment and recommended treatment
Consent to associated risks:

I am informed of the potential risks associated with proposed physiotherapy treatments. They include but are not limited to burns from application of heat and cold packs or electrotherapy modalities, redness, increased discomfort, re-injury, muscle sprains and strains and fractured bones. I understand I may have increased soreness following treatment and will inform the therapist immediately of any concerns.
Consent to collect and release information:

I give my informed consent to the employees of the Clinic to obtain and/ release information from/to physicians, lawyers, family members, insurance companies, case managers, employers, hospitals or health care practitioners as deemed necessary for my continuing care or the processing of my claim. I also release the employees of the clinic from any and all claims directly associated with the release of the information. I give permission for clinic employees to contact me through phone calls and leave a message when required.

I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent is voluntary for the entire course of assessment and treatment. This consent cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
Patient Name (Legal Guardian if under 18)
Signature

Clear
Date

Day Month Year
Date
Should be Empty:

Extended Health Benefits

Please indicate where the pain is located

Authorization and Consent

Additional Consent Applicable to Plan Members Only

YOUR PRIVACY IS OUR PRIORITY

Patient Consent Form For Collection, Use and Disclosure of Personal Information

Patient Consent

Physiotherapy Informed Consent Form