Intake form

155 Fifth St

Lac Du Bonnet, MB R0E 1A0

(204) 340-6966

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Intake form
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Home
Intake form
Physio Dan Blog
Privacy Policy

Please take a few minutes to fill out this form before your initial appointment.

Contact Information

Full name

Date of birth

Phone number

Address

Emergency contact information

Emergency contact full name

Emergency contact phone number

Medical information

Insurance provider

PHIN number (9 digits)

Physician

To your knowledge, do you have any of the following conditions?

Diabetes Hepatitis AIDS Hemophilia A recent operation A major heart condition A pacemaker Taking anti-coagulants (blood thinner) Pregnant None of the above

Are there any other medical conditions your physiotherapist should be aware of?

Please provide a list of medications you are currently taking:

Injury and symptoms

Please provide some detail regarging your pain or discomfort:

Please select the number that best indicates your pain level in the past 24 hours ( 1 = no pain, 10 = unbearable)

Was your injury work related?

Was your injury a result of a motor vehicle accident?

What are you hoping the physiotherapist can help you with (goals of treatment)?

I agree to a physiotherapy assessment and treatment by a Registered Physiotherapist. I understand that on completion of my assessment, the physiotherapist will discuss the specific treatment plan recommended for me. Any complications or side effects will be discussed with me by my physiotherapist. I understand that treatment will include therapeutic and/or strength and conditioning exercises, and include manual therapy techniques and educational components regarding how to manage my condition.

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Top Blogs

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Forms & Privacy

Intake form
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Contact

155 Fifth St, Lac Du Bonnet
(204) 340-6966
daniel@sokphysiotherapy.ca