Client Intake - Resolution Physiotherapy & IMS Clinic 2019 - OLD - no longer using

Please fill in the following client information questionnaire to the best of your ability.

We take the security of your personal information very seriously. This is why we utilize the most secure version of Survey Monkey available which is in compliance with all Health Information Protection standards as well as federal and provincial legislation.

If you would like further information, please take a moment to review Resolution Physiotherapy & IMS Clinic's privacy policy here PRIVACY POLICY. If you would like a paper copy of our policy or have any questions regarding our privacy policy, please contact our Health Information Custodian, Mandi Hayes at 705-252-5200 or mandihayes@resolutionclinic.com.

We thank you for taking the time to fill in this documentation.

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* 1. Client

Surname

First Name

Date of Birth (mm/dd/yyyy)

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* 2. Contact Info

Apartment

Street

City

Province

Postal Code

Home Phone

Cell Phone

By providing your email address, you are consenting to receive email appointment reminders, responses to any emails you send to us, and customer satisfaction surveys from Resolution Physiotherapy & IMS Clinic. If you would prefer NOT to receive any of the above, please contact us and we will happily comply with your request.

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* 3. Please choose the reason you are coming to us for treatment. Choose more than one answer if you are seeing us for multiple issues. If your reason is not included in this list or you wish to include more information, please complete the section labelled 'other'.

TMJ/jaw pain or dysfunction

neck pain or dysfunction

headache

upper back pain or dysfunction

low back pain or dysfunction

hip pain or dysfunction

knee pain or dysfunction

ankle pain or dysfunction

foot pain or dysfunction

shoulder pain or dysfunction

elbow pain or dysfunction

wrist pain or dysfunction

hand pain or dysfunction

concussion

pelvic health related disorders

pediatric disorders

running assessment

custom orthotics

custom bracing

Other (please specify)

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* 4. Patient Specific Functional Scale:
Please list up to 3 important activities that you are unable to do or are having difficulty performing as a result of your pain or dysfunction.

Activity 1:

Activity 2:

Activity 3:

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* 5. Please rate how difficult each activity is on a scale of 0 (unable to perform the activity) to 10 (able to perform activity at the same level as before injury or problem).

	unable to perform activity 0	1	2	3	4	5	6	7	8	9	able to perform activity at same level as before injury or problem 10
Activity 1:	Activity 1: unable to perform activity 0	Activity 1: 1	Activity 1: 2	Activity 1: 3	Activity 1: 4	Activity 1: 5	Activity 1: 6	Activity 1: 7	Activity 1: 8	Activity 1: 9	Activity 1: able to perform activity at same level as before injury or problem 10
Activity 2:	Activity 2: unable to perform activity 0	Activity 2: 1	Activity 2: 2	Activity 2: 3	Activity 2: 4	Activity 2: 5	Activity 2: 6	Activity 2: 7	Activity 2: 8	Activity 2: 9	Activity 2: able to perform activity at same level as before injury or problem 10
Activity 3:	Activity 3: unable to perform activity 0	Activity 3: 1	Activity 3: 2	Activity 3: 3	Activity 3: 4	Activity 3: 5	Activity 3: 6	Activity 3: 7	Activity 3: 8	Activity 3: 9	Activity 3: able to perform activity at same level as before injury or problem 10

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* 6. Interpretation of scores (for office use only)

Total Score: sum of activity scores ___ / number of activities _ = ______ MDC (chronic pain) = 2 SCORE RANGE = 0 (max disability) to 10 (no disability)

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* 7. How did you hear about us?

Your Family Doctor

Your Nurse Practitioner

Your Dentist

Another Doctor

Another Physiotherapist

Your Massage Therapist

Your Chiropractor

A friend

Another client of Resolution

Web search

Magazine article

Other (please specify)

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* 1. Client

Question Title

* 2. Contact Info

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* 3. Please choose the reason you are coming to us for treatment. Choose more than one answer if you are seeing us for multiple issues. If your reason is not included in this list or you wish to include more information, please complete the section labelled 'other'.

Question Title

* 4. Patient Specific Functional Scale:Please list up to 3 important activities that you are unable to do or are having difficulty performing as a result of your pain or dysfunction.

Question Title

* 5. Please rate how difficult each activity is on a scale of 0 (unable to perform the activity) to 10 (able to perform activity at the same level as before injury or problem).

Question Title

* 6. Interpretation of scores (for office use only)Total Score: sum of activity scores _____ / number of activities _____ = ________ MDC (chronic pain) = 2 SCORE RANGE = 0 (max disability) to 10 (no disability)

Question Title

* 7. How did you hear about us?

* 4. Patient Specific Functional Scale:
Please list up to 3 important activities that you are unable to do or are having difficulty performing as a result of your pain or dysfunction.

* 6. Interpretation of scores (for office use only)

Total Score: sum of activity scores ___ / number of activities _ = ______ MDC (chronic pain) = 2 SCORE RANGE = 0 (max disability) to 10 (no disability)