O CONNOR REHAB & WELLNESS CLINIC. Patient Information Record

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1 Patient Information Record Date: Patient s Name: Last First MI Address: Street City Province Postal Code Home Phone ( ) Work ( ) Cellular( ) (Please circle best number to reach you during the day) Address: Sex: M F Date of Birth: / / Age: Health Card #: / / DD MM YY Employer: Occupation: How did you learn about The O Connor Clinic? Doctor / Former Patient / Friend / Internet / Yellow Pages /Other Name: Emergency Information Person to Call: Phone: ( ) Relationship: Insurance Information as Applicable Extended Health Care Company: Policy Number: ID Number: Motor Vehicle Insurance Company: Policy Number: WSIB Claim Number: Most insurance companies cover O Connor Rehab & Wellness Clinic services as an approved provider. We will assist you in obtaining reimbursement by providing you with an itemized receipt, which you can send, as is, to your insurance company for reimbursement. Please present your insurance card to the receptionist so that we may assist you with your insurance reimbursement. Your signature below indicates you are financially responsible for all charges incurred. Signature of Patient or Legal Guardian:

2 History of Injury Questionnaire Date: PT RMT DC JORDAN DUFFY HBK, DPT, RPT; MONA IMENPOUR HonBSc, DPT, PTR Devorah Eisenman BHK, RMT; Jessamyn Nitsch RMT; Sandra Lauzon RMT; Janine Viret RMT DR. LEN HERMAN BSc, DC, CCRD Patient Name: Date of Birth: Injured Joint: Right: Left: Date of Injury: Briefly describe the history of your injury: Major Symptoms: Pain / Swelling / Stiffness / Weakness / Instability / Clicking / Numbness Describe your symptoms: What makes the symptoms worse? What makes the symptoms better? Pain (circle): At rest None Severe With Activity None Severe Does the pain wake you up at night? Yes No Swelling at its worst: None Mild Moderate Severe Occupation: Have you had any injury to this area before? Yes No If yes, when? Diagnosis: Treatment given: Surgery (if applicable) Date: Surgeon and Hospital: What activities/sports do you participate in: What activities are you unable to participate in: What are your goals for therapy? 1

3 History of Injury Questionnaire Date: PT RMT DC JORDAN DUFFY HBK, DPT, RPT; MONA IMENPOUR HonBSc, DPT, PTR Devorah Eisenman BHK, RMT; Jessamyn Nitsch RMT; Sandra Lauzon RMT; Janine Viret RMT DR. LEN HERMAN BSc, DC, CCRD Patient Name: Date of Birth: Who is your family doctor or referring physician: Address: Phone Number: What other health care professionals have you seen for this problem? Diagnosis and Treatment given: Have you had any diagnostic images (Xray, MRI, Ultrasound, CT, etc) of this joint? Yes No Results: General Health: Poor / Fair / Average / Good / Excellent Current Medical History: Diabetes Type: Cardiac Disease Cancer High Blood Pressure Low Blood Pressue High Cholesterol Smoker Asthma Depression Seizure Disorder Skin Condition Stroke Weight Loss Recent Cold/Flu Bowel/Bladder Thyroid Metal Implants Headaches Shortness of Breath Arthritis Joint Replacement Alcohol Use Number of drinks/week: Other: Past Medical History (including surgeries, major illnesses): Past Family Medical History (including surgeries, major illnesses): Medications, special dietary habits, & supplements: Allergies: 2

4 Informed Consent to Physiotherapy Treatment & Assessment Doctors of Chiropractic, Physiotherapy, Medical Doctors and those who use manual therapy techniques such as spinal mobilizations are required to advise patients that there are or may be some risk associated with such treatment and assessment. In particular, you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains/ sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy mobilization/manipulation; b) There are reported cases of stroke associated with visits to medical doctors and physiotherapists. Research and scientific evidence does not establish a cause and effect relationship between physiotherapy treatment and the occurrence of stroke rather, recent studies indicate that patients may be consulting medical doctors and physiotherapists when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical mobilization/manipulation is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused by spinal adjustments or other physiotherapy treatment; d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy. Please inform us if you have an allergy to latex or a sensitivity to heat; e) The Health information custodian for your health information is the owner and proprietor of WRI Group, therefore your file in its entirety will be available for at least 10 years from the date of discharge. The documents available in your record are of a multidisciplinary model, and will be available for this time period for all clinicians or therapists that you see during your care plan. f) Please note that there are multiple Physiotherapists available to serve you and they are all noted on your intake forms. I acknowledge I have discussed or have had the opportunity to discuss with my Physiotherapist the nature and purpose of Physiotherapy assessment and treatment in general and my treatment in particular as well as the contents of this consent. I consent to the Physiotherapy assessment and treatment offered or recommended to me by the Physiotherapist. I also consent to treatment delegated by my Physiotherapist from other physiotherapy care providers. I intend this consent to apply to all my present and future Physiotherapy Assessment and Treatment. Dated this day of, 20. Patient Signature (Legal Guardian) Witness Signature Name: Name: Patients Date of Birth: (MM/DD/YY)

5 Informed Consent to Physiotherapy Support Personnel Physiotherapy Support Personnel (Physiotherapy Assistants) are required to obtain informed consent from each patient or his/her substitute decision maker for their involvement in the delivery of the physiotherapy treatment plan. It is required to explain to each patient the relationship between the physiotherapist and the physiotherapist support person for the purposes of clarifying their individual roles and responsibilities in the assessment, reassessment and progression of the physiotherapy treatment plan. The Physiotherapy Assistant will perform usual treatment with respect to the respective care plan for your injury. The Physiotherapy Assistant will not perform assessment, Re-assessment or provide care not outlined in your respective care plan. I acknowledge I have discussed or have had the opportunity to discuss with my Physiotherapist the nature and purpose of the Physiotherapy Assistant s role in treatment in general, and my treatment in particular, as well as the contents of this consent. I consent to treatment delegated by my Physiotherapist to other physiotherapy care providers. I intend this consent to apply to all my present and future Physiotherapy Treatment. Dated this day of, 20. Patient Signature (Legal Guardian) Witness Signature Name: Name: Patients Date of Birth: (DD/MM/YY)

6 Consent to Release Confidential Information DATE: PATIENT NAME: PATIENT ADDRESS: DATE OF BIRTH: (day/month/year): / / I hereby grant the representative of O Connor Rehab & Wellness Clinic permission to release information including reports regarding my current and/or past condition (s) to my general health practitioner/health care practitioner/insurer or Workplace Safety and Insurance Board (if applicable). PATIENT S SIGNATURE

7 Massage Therapy/Physiotherapy/Chiropractic Fee Schedules MASSAGE THERAPY FEE SCHEDULE LENGTH OF TREATMENT FEE 30 MINUTES $ $6.50 HST (total $56.50) 45 MINUTES $ $8.45 HST (total $73.45) 60 MINUTES $ $10.40 HST (total $90.40) 90 MINUTES $ $14.95 HST (total$129.95) CHIROPRACTIC FEE SCHEDULE DESCRIPTION OF SERVICE FEE Initial Examination $ (Includes1 st treatment) Subsequent Treatment $ Re-Evaluation $ X-Ray Reading $ Screening Examination $ PHYSIOTHERAPY FEE SCHEDULE DESCRIPTION OF SERVICE FEE Initial Examination $95.00 Subsequent Treatment $65.00 FEES ARE PAYABLE IN FULL AT THE COMPLETION OF EACH VISIT (Unless Special Arrangements have been made with the Office Manager or Clinic Director) WSIB CASES: Physiotherapy fees are fully covered once approval is received from the WSIB. Fees are paid according to the pre-set WSIB fee schedule and are payable directly to the clinic. The patient is responsible for physiotherapy fees if the WSIB refuses the claim for payment. MOTOR VEHICLE ACCIDENT/PERSONAL INJURY CLAIMS: Physiotherapy and related services are directly billed to 3 rd party payers (Extended Health Carrier, Auto Insurer, Lawyer, etc.) assigned to your case. The patient is directly responsible for physiotherapy fees and related services as a direct result of the motor vehicle accident/personal injury should your claim be denied. PLEASE BE REMINDED THAT THE ABOVE MASSAGE TIMES ALLOW A FEW MINUTES FOR ROOM CHANGE OVER. SEVERAL EXTENDED HEATH PLANS REQUIRE A MEDICAL REFERRAL NOTE TO CLAIM PHYSIOTTHERAPY AND / OR MASSAGE FEES. WE WILL ASSIST YOU TO FIND THIS OUT UPON REQUEST. Patient Name:

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