Click here
About Us
Services
All Services
Physiotherapy
Orthotics
Braces
Stockings
MVA
WSIB
Blog Page
Contact Us
Forms
Book Appointment
About Us
Services
All Services
Physiotherapy
Orthotics
Braces
Stockings
MVA
WSIB
Blog Page
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
