Patient Intake Form Patient Intake Form * = Required FieldPersonal InformationName* First Last Address* Street Address City Province *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone*Mobile PhoneWork PhoneDate of Birth* YYYY slash MM slash DD E-mail Address Occupation* Length of time in position* Emergency ContactEmergency Contact Name* Emergency Contact Relationship* Phone*How did you hear about our clinic?How did you hear about our clinic?*How did you hear about our clinic? (Please select one)Walk-inDoctorFriend or FamilyGoogleWebsiteSocial Media (Facebook, Instagram, etc.)OtherDoctor's Name* Name* Social Media* Facebook Instagram Twitter Other* Doctor's InformationFamily Physician's Name* Family Physician's Address Street Address City Province *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Family Physician Phone*Family Physician FaxMotor Vehicle or Workplace AccidentWas your injury due to a motor vehicle or workplace accident?* Motor Vehicle Accident Workplace Accident No / Not applicable Automobile Insurance InformationInsurance Company* Date of Accident* MM slash DD slash YYYY Policy #* Claim #* Name of Policy Holder* Policy Holder Date of Birth* MM slash DD slash YYYY Have you completed the accident benefits package?* Yes No Have you been treated anywhere else for injuries sustained?* Yes No Where were you treated?* Phone number of where you were treated*Legal InformationLaw Firm Legal Representative Clerk Address Street Address City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneEmail FaxBrief description of the accident. Please include any injuries you sustained.*Workplace AccidentDate of Injury* MM slash DD slash YYYY Claim #* Case Manager* Case Manager's Phone NumberHave you been treated for injuries sustained?* Yes No Employer* Name of Supervisor* Supervisor's Phone Number*Coverage Details (if applicable)Primary CoverageInsurance Company Plan/Contract # Certificate/ID # Policy Holder's Name Policy Holder's DOB (yyyy/mm/dd) YYYY slash MM slash DD Health QuestionnaireThe information requested below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided will be kept confidentially unless allowed or required by law. Your written permission will be required to release any information. 1. What is the primary complaint, body part of issue that you are seeking treatment for?*2. Do you presently have or ever had any of the following? Check all that apply:Cardiovascular* High Blood Pressure Low Blood Pressure Chronic congestive heart failure Heart Attack Phlebitis / varicose veins Stroke / CVA / TIA Heart disease None of the above (Cardiovascular) Is there a family history of any of the above?* No Yes (Cardiovascular) Yes, there is a family history of: Respiratory* Chronic Cough Shortness of Breath Asthma Emphysema Bronchitis None of the above (Respiratory ) Is there a family history of any of the above?* No Yes (Respiratory) Yes, there is a family history of: Infections* Hepatitis Skin Conditions TB HIV Herpes None of the above Skin conditions: Head / Neck* History of Headaches History of Migraines Vision Problems Vision Loss Ear Problems Hearing Loss None of the above Other Conditions* Loss of Sensation Diabetes Onset Diabetes Allergies / Hypersensitivity Cancer Arthritis Epilepsy None of the above (Other Conditions) Where? (Other Conditions) To what? Type of reaction? Is there a family history of arthritis?* No Yes Don't know (Arthritis) Where? WomenPregnant? No Yes Due Date* MM slash DD slash YYYY Gynecological Conditions? No Yes (Gynecological Conditions) What? 3. Please give a list of all surgeries, past injuries or major dental work you have had:4. Please provide a list of your current medications and conditions it treats:5. Do you have any other diagnosed diseases or medical conditions? (eg. Digestive conditions, hemophilia, osteoporosis, mental illness)* Yes No Please describe 6. Do you have an internal pins, wires, artificial joints or special equipment?* Yes No ConsentPlease read the following carefully and fully: Palermo + Physiotherapy & Wellness Centre is a multidisciplinary health care provider where the practitioners work in conjunction to provide you, the patient, thorough care and treatment. All staff members are required to sign a confidentiality form with regards to your personal information and are trained in appropriate use and protection of your information. All handling of your information is compliant with existing college guidelines and provincial and federal legislation. Our clinic uses your information to ensure you receive the best care.I give Palermo + Physiotherapy & Wellness Centre my consent to release / obtain information from the following individuals with respect to:* Physician(s) Insurer Family Member Employer Other None of the above / not applicable Physician(s)* Insurer* Family Member* Employer* Other* E-mail I give permission for Palermo + Physiotherapy & Wellness Centre to use the email provided to send reminder emails of scheduled appointments, for paperless billing and for information regarding changes in clinics offerings. Payment Information* I understand that payments for services at Palermo + Physiotherapy & Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment. Cancellation of Appointment* Palermo + Physiotherapy & Wellness Centre requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $45.00 cancellation charge may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment. Patient/Guardian Name* Date (yyyy/mm/dd)* YYYY slash MM slash DD Signature* Reset signature Signature locked. 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