Yoga Therapy Intake Form

* = Required Field
Personal Information
Name*
First Last
Address*
Street Address City Province Postal Code
Home Phone
Mobile Phone
Work Phone
Date of Birth*
Date Format: YYYY slash MM slash DD
E-mail Address
Occupation*
Length of time in position*
Emergency Contact
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone*
How did you hear about our clinic?
How did you hear about our clinic?*
Doctor's Name
Name
Social Media
- Facebook
- Instagram
- Twitter
Other
Doctor's Information
Family Physician's Name*
Address*
Street Address City Province Postal Code
Phone*
Fax
Coverage Details (if applicable)
Primary Coverage
Insurance Company
Plan/Contract #
Certificate/ID #
Policy Holder's Name
Policy Holder's DOB (yyyy/mm/dd)
Date Format: YYYY slash MM slash DD
Health Questionnaire
The 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?
Women
Pregnant?
- No
- Yes
Due Date*
Date Format: 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
Consent
Palermo Physiotherapy and 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 and 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 and 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 and 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*
- I understand that Palermo Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $25.00 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.
Informed Consent for Assessment and Treatment (Yoga Therapy)
During your initial visit, the Yoga Therapist will discuss movement challenges and suggest a treatment plan. The success of your treatment is dependent upon your participation in the treatment plan agreed upon with your Yoga Therapist. Yoga Therapy treatment techniques may include, but are not limited to: movement, range of motion, stretching, strengthening, poses and breathing. Throughout your treatment, should you have any questions or concerns about any recommended treatment, inform the therapist immediately so rationale for treatments can be given and/or adjustments can be made.
Rendering of Evaluations, Treatments and/or Services*
- I hereby consent to the rendering of evaluations, treatments and/or services as communicated by the Yoga Therapist named below. My consent is voluntary and I intend this consent to cover the entire course of assessment/treatment commencing on the date indicated below. I understand that I may ask questions at any time regarding the assessment and treatment and that this consent may be withdrawn at any time.
Patient/Guardian Name*
Date (yyyy/mm/dd)*
Date Format: YYYY slash MM slash DD
Signature*
Comments
This field is for validation purposes and should be left unchanged.