Confidential Health Form - Toronto's Best Health Club - Sport Medicine, Fitness, Weights, Personal Training, Physio and Classes!

Name *

Address *

Phone *

General Medical Information:

Extended Health Insurance (name of company & policy/claim # or write no insurance)

Occupation *

Medical Doctor *

Policy Number

ID/Certificate Number

Date of Birth *

Hours at a computer daily *

Reason for attending our office

What brings you into our clinic today? *

Location of pain *

Is the pain local or radiating? *

How long has the pain been going on? *

Is the condition getting worse? *

Yes

No

Constant

Comes & goes

Pain is aggravated by? *

Pain is relieved by? *

Did this complaint start with an accident or traumatic injury? *

Yes

No

Medical History

General Health *

Good

Fair

Poor

Previous Injuries?

Other Health Problems?

List any surgical procedures & dates

Medication/condition it treats

Family Medical History *

Alternative treatments tried?

Have you had previous Physiotherapy Treatment?

If yes, when?

No

Why have you had previous Physiotherapy Treatment?

Where have you had previous Physiotherapy Treatment?

Have you had previous Chiropractic Treatment?

If yes, when?

No

Why have you had previous Chiropractic Treatment?

Where have you had previous Chiropractic Treatment?

Have you had previous Acupuncture Treatment?

If yes, when?

No

Why have you had previous Acupuncture Treatment?

Where have you had previous Acupuncture Treatment?

Have you had previous Massage Treatment?

If yes, when?

No

Why have you had previous Massage Treatment?

Where have you had previous Massage Treatment?

Consent to Treatment (Required) *

I consent

Consent to Treatment Details

Physiotherapy Consent to Treatment
I, (the "Patient")hereby consent to the assessment and to the treatment to be performed by the Registered Physiotherapist named below at The Health Centre at The King West Club.
The Patient understands that treatment may include treatments for therapeutic, preventative, palliative, diagnostic, cosmetic, or other health related purposes.
The Patient understands that they may not rescind this consent, except upon reasonable prior notice delivered and given to the Registered Physiotherapist, in writing.
The Patient understands that they may not amend this consent, except upon prior agreement with the Registered Physiotherapist, such agreement to be in written form prior the commencement of such amendment.
The Patient further understands that the clinical, psychological and any other information, which is gathered during the course of my treatment, is confidential buy may be shared with my insuring agents, third party payers and/or physician(s) upon request in writing to do so.
The Patient has read the above consent, and has have had the opportunity to ask questions about its content. This consent will cover the physiotherapy assessment and entire course of treatment.

Chiropractic Consent to Treatment
Doctors of chiropractic, medical doctors and physiotherapists who use manual therapy techniques such as spinal adjustments are required to advise patients that there are or may be some risks associated with such chiropractic treatment. In particular you should note:
• While rare, some patients have experienced rib fracture or muscle ligament strains or sprains following spinal adjustments;
• There have been reported cases of injury to a vertebral artery following cervical spinal adjustments. Vertebral artery injuries have been known to cause stroke, sometime with serious neurological impairment, and may on rare occasion result in serious injury. The possibility of such injuries resulting from cervical spinal adjustment is extremely remote;
•There have been rare reported cases of disc injuries following cervical and lunar spinal adjustments although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal adjustments or chiropractic treatment.
Chiropractic treatment, including spinal adjustment, has been the subject of government reports and multi0disciplinary studies conducted over many years, and has been demonstrated to be highly effective treatment for spinal pain, headaches, and other similar symptoms. Chiropractic treatment contributes to your overall well-being. The risk of injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given the same symptoms.
I, (the “Patient”) acknowledge that I have discussed, or have had the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general and my chiropractic treatment in particular (including spinal adjustment) as well as the contents of this Consent.
I consent to having x-rays taken if deemed necessary to my chiropractic treatment and agree to pay any and all additional costs incurred by so doing.
I accept the results of my chiropractic treatment are not guaranteed and may not be permanent and that there may be some side effects associated with the wearing of prescribed orthotics.
I consent to the chiropractic treatments offered or recommended to me by my chiropractor, including spinal adjustment. I intend this Consent to apply to my entire present course of chiropractic treatment and any and all future chiropractic treatment(s) performed at The Heath Centre at Cardio-Go’s King West Club.


CONSENT TO REGISTERED MASSAGE THERAPY TREATMENT
I, the undersigned (the "Patient"), hereby consent to massage therapy treatment (the "Treatment") by the Massage Therapist at Cardio-Go's Health Centre at the King West Club (the "Club").  All information in my file will be kept confidential, although, subject to my prior consent, my file may or will be shared among treating therapists and/or between the professionals in order to facilitate that the utmost quality and care is received.  I understand that I will not be asked to remove any clothing above and beyond my personal level of comfort and that only the area of Treatment may be uncovered at any given time.  I understand that I can, at any time, alter or change anything the Massage Therapist is doing, or stop the Treatment completely for any reason if I so choose.
Mechanical modalities include but are not limited to: interferential current (IFC), muscle stimulation (NMES), Transcutaneous electric nerve stimulation (TENS), ultrasound, cold LASER therapy, and ice therapy. Treatment is guaranteed to be supervised by the Registered Massage Therapist and will be performed and monitored only by a qualified Registered Massage Therapist.
The Patient agrees to communicate all of my questions and concerns regarding the Treatment to the Massage Therapist, especially any concern that my well-being is being compromised.  The Registered Massage Therapist has explained and I am aware that I may experience possible side effects from the Treatment, such as temporary discomfort within muscles (24 – 48 hours post-treatment), bruising and temporary dizziness.
The Massage Therapist has explained the following to the Patient:
	•	the nature, purpose and expected benefits of the Treatment;
	•	the material risks and any potential side effects of the Treatment;
	•	alternate courses of action available to me;
	•	any likely consequence to me not receiving the Treatment.

The Patient has asked any and all questions I have concerning the Treatment and the Massage Therapist has answered all of the questions to the satisfaction of the Patient.  
PLEASE NOTE! A missed appointment without 24-hour notice of cancellation will be billed to your account.

Consent to Cancelation Policy (Required) *

I consent

Cancellation & No-Show Policies

Your appointment time is reserved especially for you. If you are unable to keep your allotted time, we kindly ask that you give us a minimum of 24 hours advanced notice in order for us to give our therapist a reasonable amount of time to fill the appointment slot. Because your therapist get affected directly when appointments are missed, or when appointments are cancelled with less than 24 hours notice, we will charge a fee. If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending on how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of treatment actually given, you will be responsible for the full session. Please understand that appointment reminders are a courtesy. In the event that we were unable to contact you, you are still responsible for showing up at your allotted treatment time. Our therapist also gratefully respect you and your time. We understand that all our patients have busy lives and, as such my our therapists will make sure that all appointments begin and end on time. Since all services are by appointment we ask for a valid credit card to hold your appointment. You will not be charged until services are rendered.You will be charged if you do not call to cancel 24 hours prior or are a no-show for your appointment. 

Please remember, if you need to cancel an appointment we require at least 24 hours notice.

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