Step 1 of 3 33% Date* YYYY slash MM slash DD Personal InformationName* First Last Personal Health Number* Home Address* Street Address Address Line 2 City Postal Code Email Address* Home PhoneCell PhoneBusiness PhoneBirth Date* YYYY slash MM slash DD Height* Weight* Marital Status* M S W D Current Occupation* Family Doctor (GP)Name First Last Location Phone NumberEmergency ContactName First Last Phone NumberRelationship Other InformationWhom can we thank for your referral? We would like to send them a token of our appreciation. Is this a workplace injury?* Yes No Please be advised that we do not accept WCB cases. Is your injury the result of a motor vehicle accident?* Yes No If yes, additional intake forms are required. The healthcare team in this clinic meets regularly to discuss interdisciplinary co-treatment of our patients. If you do not wish us to discuss your case, please check here I do not wish you to discuss my case Consent I consent to my information being used in future researchOur clinic is committed to evidence-based practice and contributing to the scientific research community. All patient information used in research is kept strictly confidential and is used only with permission of the patient. Do you consent to allow your information to be used in future research? Missed office Visits: A charge of $80 will be made in the event of a missed office visit, or if less than 24 hours’ notice is given when canceling an appointment. Re-examinations: Re-examinations are done in the event of a six month time lapse between office visits Health InformationHave you had any previous treatment to your knee? Yes No For what reason? What approach was taken? In your own words, please describe your chief complaint and when you first noticed the problem.What seems to make the problem better?What seems to make the problem worse?What type of pain is it? Sharp Stabbing Achy Burning Dull Diffuse Localized Does the pain radiate? Yes No At what time of the day does your pain seem to be at its worst? Does your knee Lock Make cracking noises Give out on you Rate the pain you are experiencing now0123456789100 is no pain, 10 is severe pain Physical HistoryPlease mark a 1 beside any conditions you have had in the past Please mark a 2 beside any condition that you have presently Musculoskeletal systemNeck Problems 1 2 Upper back problems 1 2 Shoulder problems 1 2 Elbow/wrist problems 1 2 Low back problems 1 2 Knee problems 1 2 Ankle/foot problems 1 2 Arthritis 1 2 Nervous systemNumbness 1 2 Loss of feeling 1 2 Headaches 1 2 Dizziness 1 2 Fainting 1 2 Confusion 1 2 Depression 1 2 Forgetfulness 1 2 Cardio-Vascular-Resp.Chest pain 1 2 High blood pressure 1 2 Difficult breathing 1 2 Persistent cough 1 2 Coughing phlegm/blood 1 2 Lung problems 1 2 Varicose veins 1 2 Diabetes 1 2 Hypoglycemia 1 2 Genito-Urinary systemPainful urination 1 2 Excessive urine 1 2 Scanty urine 1 2 Discolored urine 1 2 Gastrointestinal systemPoor appetite 1 2 Excessive hunger 1 2 Abdominal pain 1 2 Excessive thirst 1 2 Nausea/vomiting 1 2 Diarrhea 1 2 Constipation 1 2 Bloody/black stool 1 2 Liver/gallbladder trouble 1 2 Weight trouble 1 2 Ear, Eyes, Nose, ThroatEye problems 1 2 Vision problems 1 2 Ear discharge 1 2 Ear pain 1 2 Ear ringing 1 2 Hearing loss 1 2 Sore throat 1 2 Allergies 1 2 Hoarseness 1 2 FemalePremenstrual syndrome 1 2 Abnormal vaginal discharge 1 2 Abnormal vaginal bleeding 1 2 Pregnancy 1 2 Breast pain, and/or lumps 1 2 Your first visit to the office includes both an initial consultation as well as an office visit. At the discretion of the doctor, your first visit may not consist of actual treatment. Attire/Hygiene Some treatments necessitate direct skin contact. Please bring shorts to each appointment and bathe before attending your appointment. Please refrain from wearing any cologne, perfumes or scented lotions while in the clinic.