PATIENT INTAKE FORM Direct Billing - Motor Vehicle Accidents - WCB Find LocationFind us on a Google map. Patient BookingCall or use contact form. ServicesLearn how we can help. Patient Intake If you haven't seen us for this particular issue before, please fill out this form before your appointment. Choose the therapist that you'll be seeing.*UnknownMichael Kirby, PTGloria Kanuka, PTCraig Rohla, PTName* First Last Date of Birth* Date Format: MM slash DD slash YYYY OccupationPersonal Healthcare Number (PHN)Please provide prior to the appointment if you do not have it handy.Is this a Worker's Compensation Board (WCB) claim or do you plan on filing for WCB?* Yes No WCB claim number (if you have it already)Employer*Company contact / supervisor*Employer Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Employer Phone Number*Date of Injury* Date Format: MM slash DD slash YYYY Describe how injury occurred (ie. describe the specific event(s) or if it was gradual, describe how it felt leading up until now) Example: I woke up 3 weeks ago with right shoulder pain and it has gradually worsened until now.*Describe the areas of your body that you're concerned about (Example: right shoulder, upper back and right arm).How long have you had your current issue(s)? Please separate by body part / issue if you have multiple complaints. For example: Right shoulder pain - 3 years, Right forearm - 1 week.What makes your symptoms feel worse? Example: RIght shoulder - lifting anything about shoudler height. Forearm - when I sleep at night.Does anything make your symptoms feel better? If so, please describe. Example: Putting heat on my shoulder feels much better. When I don't use my shoulder for any activities I feel almost no pain.Have you had any previous treatment for this injury / these injuries? Yes No Describe your previous treatments the best you can! Most importantly, if there was anything helpful or anything that made it feel worse, we like to know those things.Is there anything else you would like to describe about your current complaints? Any additional information can be helpful to get started. Your physiotherapist will be asking you much more during your appointment as well, so don't feel pressure to capture it all on here.Privacy Policy* I agree to the website privacy policy.Signature*
