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About Us
Services
All Services
Physiotherapy
Orthotics
Braces
Stockings
MVA
WSIB
Blog Page
Our Staff
Contact Us
Forms
Book Appointment
Click here
Step 1: Download below files.
Markham Gateway Physio & Wellness Center Consent Form
Download
Telus Electronic Transmission Authorization Consent Form
Download
Step 2: Fill out, sign and save them.
Step 3: Fill out below intake form and upload the two signed forms.
Personal Information
Today's Date
*
First Name
*
Last Name
*
Address
*
City
*
State/Province
*
ZIP / Postal Code
*
Home Phone
Cell Phone
*
Office
Extn.
DOB
*
Male
Female
Height
*
CMS
INCHES
Weight
*
KGS
LBS
Marital Status
*
Married
Single
Widow
Divorced
No. Of Children
*
Billing Information
Health Card Number
*
Province
*
Insurance Name
*
Insurance Number
*
MVA
*
Yes
No
If Yes: Provide Details
WSIB
*
Yes
No
If Yes: Provide Details
Referral Source
Reason for the Physio Consultation
*
Referral
*
Physician
Self
Dr.
Family Physician Details
Current Surgery
Previous Surgical History
Are you on blood thinners?
*
Y
N
From
Reason
Work and Social History
Employer
*
Occupation
*
Smoker
*
Y
N
Alcohol
*
Y
N
Recreation/Hobbies
*
Current Medications List
Past Medical History: (Please check below)
Tuberculosis
Heart disease/ pacemaker
Blood pleasure
Osteoporosis
Infections
STD/HIV
Diabetes
Kidney disease
Asthma/Allergies
MVA
Thyroid Issues
Arthritis
Ulcers
Lung disease
Blood clots
Neurological conditions
Fibromyalgia
Stroke
Cancer/Anemia
Depression
Other
Please check if your immediate family had any of the below conditions: (Parents, Brothers, Sisters)
Cancer
Thyroid Disease
Arthritis
Lung Disease
Blood Clots
Stroke
Depression
Heart Disease
Blood Pressure
Diabetes
Tuberculosis
Asthma/ Allergies
Other
Please check if you have RECENTLY noted any of the following symptoms:
Loss of Consciousness
Increased pain in night
Shortness of Breath
Unusual fatigue/falls
Chest pain/Angina
Loss of perianal sensation
Heavy pulsing in stomach/ tarry stools
Fever/Sweats/Chills
Menstrual changes
Changes in appetite
Abdominal pain
Coughing up blood
Bladder/ bowel issues
Unexplained weight gain/loss
Non healing wounds
Difficulty swallowing
Headaches
Heartburn/ indigestion
Lack of energy
Current Status:
What are your chief complaints?
*
When did you first notice the problem?
*
Does your symptoms seem to be getting?
*
Better
Worse
Remains
Nature of Pain:
*
Constant
Intermittent
What areas of your life seem to be affected?
*
Work
Sleep
Appetite
Intimacy
Others
Please Specify:
What activities aggravates your symptoms?
*
What activities relieves your symptoms?
*
How have your symptoms affected your routine?
*
Have you had this problem before?
*
Previous treatments for this problem:
During the past month have you been feeling down, depressed or hopeless?
*
Yes
No
During the past month have you lost or decreased interest or pleasure in doing things?
*
Yes
No
Is there something with which you would like help?
*
Yes
No
Not today
Any recent tests done? (X Rays/Ultrasound/Lab Work)
Are you pregnant or planning to? (For women)
Symptoms
How would you describe your symptoms?
*
Throbbing
Dull
Sharp
Ache
Nagging
Lightning
Pain/symptoms relieved with rest?
*
Y
N
Pain/symptoms at night:
*
Y
N
Pain/symptoms related to position change:
*
Y
N
Onset of pain:
*
Sudden
Gradual
Give a number to your pain now:
*
No pain 0
1
2
3
4
5
6
7
8
9
Worst pain 10
Give a number to your pain on a bad day:
*
No pain 0
1
2
3
4
5
6
7
8
9
Worst pain 10
Give a number to your pain on a good day:
*
No pain 0
1
2
3
4
5
6
7
8
9
Worst pain 10
I should not do physical activities that worsens my symptoms:
*
Agree
Disagree
Unsure
Upload Telus Eletronic Transmission Authorization Consent Form
*
Choose File
No file chosen
Delete uploaded file
Upload Markham Gateway Physio & Wellness Center Consent Form
*
Choose File
No file chosen
Delete uploaded file
Send Form
