Assessment Information

First Name: Middle Name: Last Name:
Home Phone: Cell Phone: Work Phone:
Street Address: City/Town: Province:
Postal Code: Email Address: MCP Number:
           
   

Injury Information

   
Present Complaint: Date of Injury:

Work Related Injury?:
X-Rays/Tests: Medications: Previous Treatment:

Please describe the areas where you have pain due to your current injury:

Over the past 24 hours, rate your pain in a scale from 1-10 where 0 = no pain and 10 = the worst pain imaginable:
           
   

Other Information

   
Date of Birth: Occupation: Employer:
Next scheduled Doctor/Specialist Appointment:
           

We kindly ask that if you must cancel or reschedule an appointment, please give us a minimum of 24 hours notice to avoid cancellation charges (price of the treatment that was scheduled to take place). Please note that these cancellation charges are the responsibility of the client, not WHSCC or any other form of third party payer.

           
           
What made you choose this clinic?: Today's Date: