Patient Registration First Name* Last Name* New Patient*YesNo Personal Information Address* City* Province*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code* Email* Home Phone* Cell Phone Gender*MaleFemale Date of Birth* Weight (kg)* Height (meters)* Care Card Number* Family Physician* Referring Physician Medical Information WCB Injury*YesNo WCB Number* Date of Injury* Are you currently a smoker?*YesNo How much and how long have you smoked?* Have you smoked in the past?*YesNo How much, how long and when did you quit?* Do you drink alcohol?*YesNo How much and how often do you drink?* Do you work or have a daily activity?*YesNo What is your occupation or daily activity?* Do you have a recreational activity?*YesNo What is your recreational activity?* Are you right-handed or left-handed?*RightLeft Do you have help or support at home?*YesNo Support Details* Do you have dependants at home?*YesNo Dependant Details* Do you use stairs in or around your home?*YesNo Stair Details* Are you responsible for your own affairs?*YesNo Affair Details* Current Medications* Allergies* Have you ever had a surgery or anaesthetic?*YesNo Please provide details of the surgery, surgeon, or complications with anaesthetics.* Have you ever experienced any significant medical illness?*YesNo Please provide details regarding the illness, treating physician, or complications.* Do you have any of the following conditions? Diabetes*YesNo High blood pressure*YesNo Heart disease or condition*YesNo Lung disease or condition*YesNo Liver disease or condition*YesNo Gallbladder disease or condition*YesNo Pancreas disease or condition*YesNo Stomach/bowel disease or condition*YesNo Urinary tract disease or condition*YesNo Reproductive disease or condition (incl. men’s prostate)*YesNo Disease or condition of the breast*YesNo Disease or condition of endocrine glands (incl. thyroid)*YesNo Mental illness or condition*YesNo Permanent disability or impairment*YesNo Rheumatological illness or condition (incl. fibromyalgia, osteoarthritis)*YesNo Any implanted device*YesNo Any metallic foreign body (incl. surgical clips, metal in the eye, shrapnel)*YesNo Please explain how you are affected by any of the above conditions.* What is the reason for referral or current complaint? Body part or area? What side of the body?*Right sideLeft side Pain*YesNo Pain Details* Locking, catching, giving way*YesNo Explain Details* Falls/near falls*YesNo Fall Details* Loss of function*YesNo Function Details* Deformity*YesNo Diformity Details* Sleep disturbance related to injury*YesNo Onset was*SuddenGradual Sleep Details* Condition is*Always presentTime to time Condition Details* Please provide details of your injury.* Please provide treatment details received so far.* What investigations have been done so far? X-rays*YesNo X-ray Location* X-ray Date* CT Scans*YesNo CT Scan Location* CT Scan Date* MRI*YesNo MRI Location* MRI Date* Bonescan*YesNo Bonescan Location* Bonescan Date* Ultrasound*YesNo Ultrasound Location* Ultrasound Date* Laboratory investigation*YesNo Laboratory Location* Laboratory Date* Additional Registration Details Did you read and sign the Facility Mission and Policies document?*YesNo If no, please explain* Do you wish to receive a copy of medical information added to the medical file with each appointment, as outlined in the Facility Mission and Policies document? (administrative fees apply to this service)*YesNo Registration completed by*PatientPhysicianOther Physician/Other Name* Registration Date* Notes:1. For conditions related to the lower extremities (leg/foot), please bring shorts.2. For conditions related to the upper extremities (shoulder/ hand), please bring a sleeveless shirt or tank top. By submitting this document, you certify that the information provided herein is true, complete, and accurate to the best of your knowledge.*I agree Submit Registration
