Privacy Policy

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General
Name: * (First)
* (Last)
Date of Birth:
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Address: (Apt)
  * (Street)
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* (Province)
* (Country)
* (Postal code)
Phone: * (Home)
(Work)
(Cell)
Your Email: *
Referral Source: *
Area of Treatment: *
Family Doctor: *
Date of Initial Visit:


ICBC
PHN#:
Claim Number:
Adjuster Name:
Adjuster Number:
Accident Date:
Lawyer:


Physiotherapy Related Questions
On a scale of 0 - 10 how would you score your pain on average?
(if 0 is no pain and 10 is the worst pain you can imagine)
Pain:

The following pertains to the activities you having the most difficulty with (eg: sitting, walking, running). Please state the activity and score (on a scale of 0 - 10) your ability on average?
(0 = unable to perform and 10 = no difficulties)
Activity 1

Activity 2

Activity 3		 Score: Score: Score:
What are your goals/expectations from your experience with us?