Tower Physio New Patient History Form
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3#120, 140 - 10th Avenue SE, Calgary, AB T2R 0A3
(403) 262 2620
|
info@towerphysio.ca
New Patient History Form
The first step in recovering from your injury is for us to know all about your pain and symptoms. Please
assist your physiotherapist by answering the following questions as completely and accurately as
possible. In order to provide you with safe and effective treatment, we also require knowledge of your
past medical history.
Thank you for your cooperation. If you have any questions or concerns with any part of this form, you
may leave it blank and ask your physiotherapist.
Name __________________________________________________________ Date __________________________
After printing out this form please
shade in the areas of pain and/
or mark an X for any areas of
numbness or pins and needles.
How long have you had this injury? _______________________________________________________________
Was there an incident that brought on the problem?
Yes - Please describe _________________________________________________________________________
No
Unsure
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Parent category: Medical