Intake Form + COVID-19 Screening

Personal Information

Name*

First Middle Last

How did you hear about us?*

Mailing Address*

Street Address Address Line 2 City Province Postal Code

Phone - Home

Phone - Cell*

Phone - Work

Email*

Birthdate*

Health Card #*

Occupation

Gender

Emergency Contact*

Phone*

Relationship*

Reason for appointment today*

Is this related to a car accident?*

No
Yes

Is this related to a work injury?*

No
Yes

Consent for Release of Information

Consent

I authorize MOVE Physiotherapy to use my mailing address, phone number and email address for appointment reminders and treatment follow up.

I authorize MOVE Physiotherapy to use and disclose my medical information for purposes of treatment, payment and health care to the following:

Family Physician

Family Physician

Physician Name*

Personal Healthcare Insurer

Personal Healthcare Insurer

Insurer*

Policy #*

Member/ID #*

Policy Holder Name*

Date of Birth*

Motor Vehicle Insurance Provider

Motor Vehicle Insurance Provider

Worker’s Compensation Board

Worker’s Compensation Board

I understand that I have the right to revoke this consent provided that I do so in writing, except to the extent that MOVE Physiotherapy has already disclosed the information based on this consent.

Health History

Are you presently being treated for any health conditions?

No
Yes

Please list health conditions*

Are you presently taking any medications/vitamins/supplements?

No
Yes

Please list medications/vitamins/supplements*

Are you currently pregnant?

No
Yes

Due Date*

Are you or were you ever a smoker?

No
Yes

Please list previous injuries and/or surgeries

Have you been to physiotherapy in the past?

No
Yes

Can you perform daily home/work activities?

All
Some
With help
Not at all

What is your current level of pain?

Please check any that apply, past or present:

Heart Condition, please list*

Stroke/CVA date*

Pacemaker year of insertion*

Swelling/Edema cause if known*

Cancer, please list type and dates*

Diabetes, please list type*

Osteoporosis, year of diagnosis*

Fibromyalgia, year of diagnosis*

Hepatitis, list type*

Epilepsy, is it controlled*

No
Yes

Date of last seizure*

Skin condition, please list*

Bowel/Bladder/GI Issues, please specify*

Respiratory Issues, please specify*

Allergies, please list*

Presence of internal pins, plates, screws or artificial joints, please list*

Are you currently immunocompromised?*

No
Yes

Please list anything else that your therapist should be aware of

Cancellation/Late Policy

If you are unable to attend your scheduled appointment you are responsible for cancelling that appointment with 24 hours notice. If you fail to do so, you MAY be charged a $25 fee. If calling outside of business hours, please leave a detailed message. If you arrive 15 minutes or more past your scheduled appointment time you may be asked to reschedule and you MAY be charged a 25$ fee.

Payment Agreement

MSI does not cover any of our services; therefore you, the client, are responsible for payment of services rendered. Payment is due at the time of your appointment. Many clients have private health benefits to offset the cost of our services. We direct bill Blue Cross and all Companies part of Teuls Health. Worker’s Compensation Board and Motor Vehicle Insurers. It is your responsibility to know the details of your plan. If you are covered under more than one policy, please note that we will only bill the primary policy. Any fees above this amount are your responsibility. (MOVE Physiotherapy reserves the right to refuse direct billing to any insurance company).

Please Note: If your claim is refused or denied by Worker’s Compensation Board, your Motor Vehicle Insurer or your personal Healthcare Insurer, you are responsible for all payments for services rendered. These fees may include, but are not limited to the following: treatment fees, product fees and fees for any forms completed during treatment.

Consent*

I accept

By submitting this form, you are acknowledging MOVE Physiotherapy’s Cancelation/Late Policy and Payment Agreement

COVID-19 Screening

Do you have NEW or WORSENING:

fever/feverish (i.e. chills, sweats)?
cough?
sore throat?
headache?
shortness of breath?
nasal congestion/runny nose?

If you answered YES, to any of the above symptoms you are not allowed to enter the clinic at this time. As per Nova Scotia Public Health Regulations, you should self-isolate at home, and call 811

Have you had close contact within the last 14 days with a confirmed case of COVID19?*

No
Yes

Have you had close contact within the last 14 days with a person being tested for COVID-19?*

No
Yes

Have you been diagnosed with COVID-19 or are waiting to hear the results of a lab test for COVID-19?*

No
Yes

Have you returned from travel outside of Nova Scotia within the last 14 days or been in contact with someone who has?*

No
Yes

Have you been told by public health that you may have been exposed to COVID-19 OR been present at one of the locations and times of the possible exposure sites listed below?*

No
Yes

Possible exposure sites: https://novascotia.ca/coronavirus/alerts-notices/#possible-exposures

If you answered YES, to any of the above then you are not allowed to enter the clinic at this time. We can book you for a TeleHealth appointment or we can reschedule you for 2 weeks from now. It is recommended you go to https://novascotia.ca/coronavirus/when-to-seek-help/ for more information on when to seek help/call 811