3570 Rutherford Road, Unit 90-92. Vaughan ON L4H 3T8
905.553.5900
905.553.8222
info@bodyworxvitality.com
Realize your BODYWORX Potential!
This information requested below will assist safe and effective treatment. Feel free to ask any
questions about the requested information. Please note that all information provided will be
kept confidential unless allowed or required by law.
Name: __________________________________ Date of Birth:________________________
Address: ____________________________________________________________________
City: ___________________________________
Postal Code: ________________________
Home Phone #:___________________________ Other Phone #:_______________________
E-mail address: _______________________________________________________________
Emergency Contact (Name & Phone #):____________________________________________
Family Physician (Name, Phone #):________________________________________________
Occupation: _______________________ How did you hear about us?____________________
Did a health care practitioner refer you to physiotherapy? Yes
No
Please list any medications and reasons for taking them: _______________________________
____________________________________________________________________________
Do you have Extended Health Insurance? ☐ YES
☐ NO Provider: _____________________
As a professional courtesy our clinic may send a progress letter to your family doctor. Do we
have your permission to do so? ☐ YES ☐ NO
Is your condition due to: ☐ Car Accident? ☐ Workplace Injury? ☐ Personal Injury?
Please indicate conditions you are experiencing AND/OR have experienced in the past.
Cardiovascular:
☐ High Blood Pressure
☐ Heart Disease/Failure
☐ Phlebitis
☐ Low Blood Pressure
☐ Blood Clots
☐ Varicose Veins
☐ Stroke
☐ Pacemaker
☐ Other: _______
☐ Emphysema/COPD
☐ Pneumonia
☐ Asthma
☐ Other:_______
Respiratory
☐ Shortness of Breath
☐ Bronchitis
Please turn over
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Chronic Conditions
☐ Diabetes - Type 1 or 2
☐ Osteoporosis
☐ Liver Disorder
☐ Skin Condition:
☐ Epilepsy/Seizures
☐ Arthritis
☐ Crohn's Disease
☐ Other:
☐ Fibromylagia
Women’s Health:
Are You Pregnant? ☐ YES
☐ NO
☐ Gynaecological Conditions/Pelvic Pain: ____________________________
General Conditions:
☐Headaches/Migraines
☐Vision Problems/Loss
☐Depression
☐ Psychological Condition:
☐Migraines
☐Thyroid
☐Dizziness
☐ Ankylosing Spondylitis
☐Hearing Loss
☐Stress
☐Gout
Other:
☐ Cancer - type / location: ______________________________________
☐ Allergies - to what: __________________________________________
☐ HIV/AIDS
☐ Tuberculosis
☐ Hepatitis -Type: ____
☐ Artificial Joints
☐ Internal pins/wires
☐ Walking aid/cane
Lifestyle:
Do You Smoke? ☐ YES ☐ NO
Do You Exercise Regularly? ☐ YES ☐ NO
Do You Drink Alcohol? ☐ YES ☐ NO
Do You Eat Well? ☐ YES ☐ NO
Significant weight loss/gain? ☐ YES ☐ NO Are You Interested In Losing Weight? ☐ YES ☐ NO
What Are Your Goals For Treatment?
____________________________________________________________________________
Please list all your involvement with other health care practitioners:
_____________________________________________________________________________________
Please list any other health issues or information which may be helpful in our care for
you:
____________________________________________________________________________
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