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Initial Intake Form

Alliston Physiotherapy + Sports Rehab

The information request 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 below will be kept confidentially unless allowed or required by law. Your written permission will be required to release any information.

Name *
Date of Birth *
Type Appintment Note
Phone
Doctor – Name
Occupation
Address
Allergies
Phone *
E-mail *
Emergency Contact Number
Health Care Number
Reason you are seeking Physiotherapy?
How long has condition existed?
In general, how is your health?
Referred for Physiotherapy by:     Doctor       Other
Have you had Physiotherapy in the past?     Yes       No

Current Medications

Name
Condition

Other medical conditions to note

(ie. pins, wires, plates, artificial joints, canes..)

Injury

Type
Date

Surgeries

Type
Date
Are you currently receiving treatment from another health care professional?




1.Do you have any heart problems?:     Yes       No
2.Do you have any thyroid problems?:     Yes       No
3.Do you have HIGH or LOW blood pressure?:     Yes       No
4.Are you currently taking any medications? :     Yes       No
5.Have you been diagnosed with arthritis?:     Yes       No
6)Do you have diabetes?:     Yes       No
7.Do you have or ever had cancer?:     Yes       No
8.Have you ever broken a bone?:     Yes       No
9.Do you have any metal fixations, plates, screws, etc.?:    Yes       No
10.Do you smoke? :     Yes       No
11.Do you have any abdominal problems, ie hernia, ulcer?:     Yes       No
12.Have you had any previous surgeries :     Yes       No
13.If female, are you or could you be pregnant?:     Yes       No
14.Have you been involved in a previous car accident?:  Yes       No
15.Do you have any allergies, skin irritations, infections, etc?:  Yes       No
16.Do you have asthma or any respiratory problems?:     Yes       No
17.Do you have any other health problems not listed above?:     Yes       No
18.Is there any other reason that you should not do physical activities?:  Yes       No
Last Physiotherapy visit?
Emergency contact person
Phone
Client’s Signature