Physiotherapy Intake Form

Physiotherapy Intake Form

The information requested below will assist the practitioner in treating you safely. Feel free to ask any questions about the information being requested. All the information requested will be kept private according to the East Meets West Health Centre Privacy Policy.

Date
Date
1. Name: *
1. Name:
2. Date of Birth
2. Date of Birth






9. Is th pain/concern getting:

10. Have you had any imaging done for this problem?
Check any that apply



13. Have you been assessed by any other care giver for this problem?
Check any that apply


15. General Health
Do you presently suffer from any of the following? Check any that apply