New Physiotherapy Patient Form Physiotherapy Personal History PAYMENT FOR SERVICES IS DUE AT THE TIME OF YOUR APPOINTMENTName* First Last Date of Birth* Address:* Street Address City Postal Code Primary Phone Number:*Alternative Phone NumberFamily Doctor: PH:FX:Location*West Hunt Club(Antares)Hunt ClubFindlay CreekBells CornersWestboroManotickCarleton PlaceKemptvillePerthRichmondRocklandChose Clinic because/referred to Clinic By?*(Please tell us how you heard of Back on Track.)Email Address* (Your email address will only be used by our clinic to communicate with you. It will not be sold or distributed.)Please, check current and previous conditions & write the approximate date besideMUSKOSKELETAL CONDITIONSOSTEOPOROSISOSTEOARTHRITISMETAL IMPLANTSPREVIOUS MOTOR VEHICLE ACCIDENTSTMJ / DENTAL APPLIANCES / DENTURESOTHERDescription* Do not forget to write approximate date of your condition SYSTEMIC / OTHERPREVIOUS SURGERIESASTHMAEMPHYSEMATUBERCULOSISTHYROID PROBLEMSRHEUMATOID ARTHRITISTUMOUR / MALIGNANCYHERNIAANXIETY DISORDERSULCERHIVDIZZINESS / FAINTINGPREGNANCYRINGING IN EARSSWALLOWING PROBLEMSRECENT WEIGHT CHANGESVISION / HEARING PROBLEMSFIBROMYALGIAKIDNEY /BLADDER /BOWEL PROBLEMSTRANSMITABLE DISEASESCARDIOVASCULAR CONDITIONSANGINA / HEART ATTACKHIGH / LOW BLOOD PRESSURECIRCULATION PROBLEMSANEMIA / BLEEDING DISORDERSPACEMAKEROTHERDescription* Do not forget to write approximate date of your condition NEUROLOGICAL CONDITIONSSTROKESEIZURESCONCUSSIONSPARKINSON'SMULTIPLE SCLEROSISOTHERDescription* Do not forget to write approximate date of your condition PLEASE LIST ANY MEDICATIONS OR ANY OTHER CONDITIONS YOU WOULD LIKE KNOWN: Name of Guardian If patient is under 16:Relationship to patient:Phone Number If different from above:THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE.* I AGREE AND BY SIGNING BELOW I HAVE READ AND UNDERSTAND THE PAYMENT AND CANCELLATION POLICIES. We require 24 hours notice for cancellations. Missed appointments and cancellations without 24 hours notice are subject to a 30$ fee.PATIENT / GUARDIAN SIGNATURE:*DATE*
