PROGRESS NOTES - Triangle Physiotherapy



PATIENT REGISTRATION FORMLast Name:First Name:Date of Birth: DD - MMM - YYYYGender: FORMCHECKBOX M FORMCHECKBOX FApt/Suite/Unit No:Street:City:Postal Code:Home Tel. #:Work Tel. #:Cell #:E-mail:Occupation:Referring Physician:Telephone:HOW DID YOU HEAR ABOUT US? (MARK ALL THAT APPLY) FORMCHECKBOX I have been here before FORMCHECKBOX Doctor’s Referral FORMCHECKBOX Yellow Pages Book FORMCHECKBOX yp.ca FORMCHECKBOX Google search FORMCHECKBOX Friend/Family/Co-Worker (please name) FORMCHECKBOX Sign Board FORMCHECKBOX Just Walked In FORMCHECKBOX Flyer FORMCHECKBOX VennGo FORMCHECKBOX Other: MEDICAL HISTORY FORMCHECKBOX Heart Disease FORMCHECKBOX Osteoporosis FORMCHECKBOX Pace Maker FORMCHECKBOX Double Vision FORMCHECKBOX Nausea FORMCHECKBOX Diabetes FORMCHECKBOX Arthritis FORMCHECKBOX Hearing Aid FORMCHECKBOX Night pain FORMCHECKBOX Dizziness FORMCHECKBOX Cancer FORMCHECKBOX Skin Condition FORMCHECKBOX Metal Implants FORMCHECKBOX Headaches FORMCHECKBOX Recent weight loss FORMCHECKBOX H. Blood Pressure FORMCHECKBOX Intra-Uterine Device FORMCHECKBOX Kidney Ailments FORMCHECKBOX Trouble with speaking/swallowing FORMCHECKBOX Are you pregnant? FORMCHECKBOX Allergies If YES, please specify Others: Have you had any major surgery? FORMCHECKBOX Y FORMCHECKBOX N If YES, please specify. 489585022860List any medications you are presently taking.Investigations: FORMCHECKBOX X-Ray FORMCHECKBOX MRI FORMCHECKBOX Ultrasound FORMCHECKBOX CT Scan FORMCHECKBOX Other: If YES, when & where? Location / symptoms you are presently experiencing (indicate on diagram):Pain Scale: Indicate the severity of your symptoms on the following scale.083820Pain Behaviour: Is your pain: FORMCHECKBOX Improving FORMCHECKBOX Worsening FORMCHECKBOX The sameIs your pain: FORMCHECKBOX Constant FORMCHECKBOX Intermittent Describe your pain (dull, ache, sharp etc.): What activities make your pain: Worse: Better: Since when are you experiencing the above symptoms?Cause of above symptoms (if known)If you wake up tomorrow & have no symptoms, what are the things/activities you would like to do?1. 2. 3. 4. 5. 6. SignatureDate ................
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