CLIENT INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
ADDRESS
City / Province
Postal Code
EMAIL
Date of Birth
Occupation
BC Care Card #
Employer
Sex
Male
Female
Family Doctor
Home Phone #
Referred By
Work #
WCB Claim #
Emergency #
ICBC Claim #
Emergency Name
Date of Injury
Extended Health Company
Primary Insurance
Member Name/ Relationship/DOB
Policy / Plan Contract #
Member ID / Cert #
Secondary Insurance
Member Name/ Relationship/DOB
Policy / Plan Contract #
Member ID / Cert #
Have you received physiotherapy, massage, chiropractic or podiatrist treatments at any other private practice clinic during the
Present Year? Yes
/ No
If Yes: Where?
When?
1. I hereby agree and understand that I am responsible for payment of both the user fees and treatments, unless this is
covered by B.C. Medical Services Plan or by alternate coverage (I.C.B.C., WSBC, or Extended Healthcare Insurance).
2. I authorize that benefits payable under the Medical Services Plan for my physiotherapy care be paid directly to Fraser
Valley Physiotherapy & Rehabilitation Centre.
3. I agree and understand that failure to provide 24 hours cancellation notice prior to any scheduled appointment will result in
a charge of $20.00, if it is a 1 hour Massage appointment it will be a $40.00 charge.
4. I hereby request and authorize release of the results of any tests performed at the X-ray Department of the Chilliwack
General Hospital to Fraser Valley Physiotherapy & Rehabilitation Centre.
5. I hereby request Fraser Valley Physiotherapy & Rehabilitation Centre to have access to the results of any medical tests
performed on me with regards to the condition for which I am seeking treatment.
6. I hereby authorize Fraser Valley Physiotherapy & Rehabilitation Centre to communicate regarding my progress to my
Insurance Company/Doctor/Lawyer or their representative.
7. I hereby understand that Fraser Valley Physiotherapy & Rehabilitation Centre must collect various amounts of personal
information in order to provide me with the best possible treatment, ensure my safety and the safety of other individuals, to
comply with professional standards and regulations. I understand that my personal information will be protected as per this
Clinic's Privacy Policy and the Freedom of Information and Protection of Privacy Protect Act (FIPPA).
Dated
February 9, 2016
Signature
Dated
February 9, 2016
Signature (if under 19, parent or legal guardian)
QUESTIONNAIRE
This is a questionnaire regarding your general medical health status. Please fill out as concisely and thoroughly as possible.
Do you have any life threatening allergies?
Yes
No
If Yes, please explain:
Have you been diagnosed with or do you have any of the following?
Heart Condition:
Yes
No
Chronic Lung Condition
Yes
No
High Blood Pressure:
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
Diabetes:
Arthritis:
Cancer:
Epilepsy:
Tuberculosis:
HIV/AIDS:
Hepatitis: A
B
C
Circulatory Condition:
Kidney Condition:
Osteoporosis:
Steel Pins:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
Have you been in hospital for any major surgery or illness?
Yes
No
Have you had any motor vehicle accidents?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem (other than your present injury) that could be made worse by
a change in your physical activity?
Yes
No
Do you know of any other reason why you should not do physical activity?
Yes
No
Have you been, or are you being, treated by any other health care worker regarding the area you
are having treated today? (ie. Chiropractor or Massage Therapy):
Yes
No
- When last checked? (>2 yrs-get cked)
Stroke:
High Cholesterol:
Pace Maker:
Asthma:
Head Injury:
Headaches:
Seizures:
Fibromyalgia/Chronic
Fatigue Syndrome:
Have you been exposed to a contagious infection? (ie. lice, scabies, rubella (German measles)?
If Yes, please explain and state how long ago:
Are you pregnant?
Yes
No
Are you presently taking any medications (prescription or otherwise)?
If Yes, please list (including dosage):
If Yes, when?
What type of treatment?
Have you had any of the following tests with respect to your current illness/injury?:
X-rays:
Yes
No
CT Scan:
Yes
No
MRI:
Yes
No
Do you have any other tests/surgery scheduled?
Bone Scans:
Bone Density:
Other:
Yes
No
Yes
Yes
If Yes, please specify:
CLIENT NAME:
enter your name
DATE: February 9, 2016
No
No
MEDICAL HISTORY
Reason for Treatment
Describe the onset
Sudden
Gradual
Date of Injury
Type of Pain
Unusual Activity
Cause of Injury
Sharp
Burning
Dull
Does the pain affect your daily activities?
Yes
Aching
Shooting
Other
What aggravates the pain?
What relieves the pain?
Is the pain worse in the
Morning
Has this condition occurred before?
No
If Yes, how?
Evening
Yes
Does your job involve extended periods of
Other
No
Was it resolved?
Sitting
Standing
Yes
Heavy Lifting
No
Computer
Please indicate with an “X” where you are experiencing pain (print only) or describe it in the space on the right.
Please indicate left or right side. If you would like to add
anything, please do so here as well.
PATIENT CONSENT
Registered Massage Therapists make every effort to ensure that your treatment is safe and effective. Massage therapy
involves manipulation of soft tissues and joints of the body, and the approach to treatment may vary depending upon the
patient´s condition(s). At any time before or during the massage therapy treatment, you have the right to ask that the
treatment or portion of the treatment be discontinued or inquire about the purpose of any technique being used. If at any time
you have any questions or concerns related to the treatment, the therapists of this clinic encourage you to communicate with
them so that there may be clarification or the modification of the treatment.
Dated: February 9, 2016
Signature _______________________________