Yoga Therapy 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 PhoneMobile 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* Emergency Contact 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* Address* Street Address City Province *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone* Fax 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 ConsentPalermo 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)* YYYY slash MM slash DD Signature*NameThis field is for validation purposes and should be left unchanged.
