Patient Intake Form

AND INFORMED CONSENT

Please fill in the following form to the best of your ability. Filling in this form will help make our appointment more efficient.

First Name

Last Name

Date of Birth

Please give a brief history of your complaint/injury.

How long have you had this complaint/injury for?

Do you have any relevant serious medical conditions? Include any current medications.

Short-Form McGill Pain Questionnaire

Please select any and all of the items that are related to your current injury/pain.

Visual Analogue Scale for Pain

Rate your pain on this sliding scale (0 least - 10 most).

Notable Symptoms Questionnaire

Please select any and all of the items that are related to your current injury/pain.

Informed Consent:

The attending therapist (physiotherapist, chiropractor, massage therapist, and kinesiologist) upon examining/assessing the patient, agrees to provide understandable information on:

1) Functional or patho-anatomic diagnosis as known/suspected.

2) The treatment being suggested.

3) The important effects, risks and side effects of the treatment.

4) Possible alternatives to having this treatment.

5) Reasonable additional procedures which may be necessary.

6) The potential risks of foregoing the suggested care.

The attending therapist (physiotherapist, chiropractor, massage therapist, and kinesiologist) may find it beneficial to perform specific controlled acts (acupuncture, dry needling, manipulation) within their scope of practice as governed by respective regulated professional bodies. Prior to these acts, the therapist will discuss with the patient the benefits and risks of the controlled acts and must receive verbal consent for the act. At any time, the patient has the right to revoke their consent for any of these controlled acts if they are uncomfortable with the treatment technique. While rare, some patients may experience short-term aggravation of symptoms as a result of manual therapy techniques.

Your Signature

I acknowledge I have read and agree to the contents of this Consent. I hereby authorize and grant permission to the therapists within the physical therapy/rehabilitation department of Leader Sports Med Ltd. to carry out any examination procedures and treatments necessary to assess and treat my condition or injury.

I authorize the health practitioners at Leader Sports Med Ltd. to access my health and medical record information for the purposes of collaboration towards my health and rehab care.

I consent to sharing my health information to all providers at Leader Sports Med Ltd.

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