WSIB Physiotherapy Initial Intake Form Employer and Work InformationDo you have a claim number?*YesNoWSIB Claim Number*Date of Injury* Date Format: DD slash MM slash YYYY Employer Name*Employer Phone #*Employer Address*Manager/Supervisor Name*Length of Time in Current Job*Employment Status at Time of Appointment*WorkingNot Working*Select OneFull TimePart Time*Select OneRegular DutiesModified Duties*Select OneRegular HoursModified HoursPersonal DetailsFirst Name*Last Name*Date of Birth (dd/mm/yyyy)* Date Format: DD slash MM slash YYYY Sex*MaleFemalePhoneHome*Mobile*WorkAddress*Occupation*Email Address* Emergency ContactName*Relation*Phone*Family Doctor DetailsDo you have a family doctor?*YesNoName*Phone*Doctor Address*How did you hear about us?*GoogleLook LocalDrive byDoctor ReferalFriend/FamilyOtherPlease describe how you heard about us*List all Sports/ ActivitiesHealth History lease check the boxes for any condition(s) you have experienced or are experiencing: Inform your physiotherapist if anything changes in your health.Respiratory Chronic cough Shortness of breath Bronchitis Asthma Emphysema Cardiovascular High / Low Blood pressure Heart attack Phlebitis Stroke Pacemaker Heart disease Easy bruising- use of blood thinning medication (Warfarin, Coumadin etc) Varicose veins Blood clots Infections Hepatitis TB HIV/ AIDS Skin Other Please Specify*Soft tissue/ Joint discomfort Neck Low back Mid back Upper back Shoulders Elbows Wrists/ hands Arms Hips Knees Ankle/ feet Legs Muscle cramping Jaw Weakness or paralysis Numbness Other Where*Where*Please SpecifyHead/ Neck Vision problems Ear problems (ex: fullness, ringing, loss) Head trauma Headaches/ Migraines Sinus problems Past whiplash injury Women Pregnant Currently Breastfeeding Menstrual Back aches Painful periods Birth control (due)*Other Conditions Diabetes Epilepsy Cancer Rheumatoid Arthritis Osteoarthritis Spinal conditions Skin conditions Chronic fatigue Weight loss or gain Disc herniation Osteoporosis Scoliosis Bone disease Allergies Loss of sensation Numbness/ Tingling Dizziness/ fainting Bladder or bowel changes Severe pain Severe night pain Pain unaffected by change in position or medication Pain with no history of injury Severe spasm Fever, night sweats Unexplained fatigue Pain with cough or sneeze Difficulty speaking or swallowing Recent nausea or vomiting TypeOnset*Please Specify*What is your general health status?Do you Smoke?*NoYesHow much*Medication*I don't take medicationI will provide a list to be photocopied on my visitYes I take medicationList all current medication you are taking*(You may also provide a list to be photocopied by our reception staff)List all Past SurgeriesInternal pins, wires, artificial joints, special equipment:Payment information: Payment for services at Footprint Health and Wellness are the responsibility of the patient and are to be paid at each visit. If a third party payer denies your claim and/ or refuses to pay for the full amount billed, you are responsible for paying the outstanding amount. I acknowledge that custom made and ordered devices are not refundable. Payment information: Payment for services at Footprint Health and Wellness are the responsibility of the patient and are to be paid at each visit. If a third party payer denies your claim and/ or refuses to pay for the full amount billed, you are responsible for paying the outstanding amount. I acknowledge that custom made and ordered devices are not refundable.Cancelation policy: Minimum of 24 hours notice is required to cancel or change an appointment. A charge may be applied if less then this is provided. Should you book an appointment and not attend, you are responsible to pay the entire cost of the appointment.Informed consent Footprint Health and Wellness is a multidisciplinary health center where all the practitioners work together to provide optimal and thorough care and treatment. All handling of your information is compliant with existing College of Physiotherapists of Ontario guidelines, Provincial and Federal legislation. I understand that the Physiotherapist is providing assessments, treatments, and services within the scope of practice as defined by the College of Physiotherapists of Ontario. Treatment techniques at Footprint Health and Wellness may include, but are not limited to: manual therapy techniques, (joint mobilizations, joint manipulations, soft tissue techniques), electrotherapeutic modalities, acupuncture, laser and exercise. I hereby voluntarily consent to my Physiotherapist to treat me within the scope of practice, and to perform any procedures necessary in the assessment of my condition. I understand I have the right to ask questions at any time about my treatment and that consent may be withdrawn at any time. I provide Footprint Health and Wellness Centre consent to share my information with people or organizations, from time to time, solely as it relates to my treatment (i.e. Family Doctor, Insurance Company, etc.). I provide consent for Footprint Health and Wellness Centre to communicate with me via email or text message reminders for my upcoming appointments, and for the purpose of paperless billing and for information regarding changes in clinics offerings (I understand that I can unsubscribe at anytime). Is Patient Under the Age of 18?*YesNoPrint Name*Parent/ or Guardian Name*Date* Date Format: MM slash DD slash YYYY Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.