New Client Form

Please note that this form is to be submitted after you have made an appointment with the office.

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


ICBC/WCB
Care Card Number#:
Claim Number:
Adjuster/Case Manager:
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?