New Patient Intake Form

Please note: This form is only for patients who have been referred by a family physician.

Due to limited space in the waiting room, patients can only have one other person accompanying them for their appointment.

Patient Information

Please enter your information as it appears on your health card.

First Name

Last Name

Date of birth

Age

Height

Weight (specify lbs or kgs)

Occupation

Referring doctor

Your email address

Symptoms

Which is your dominant hand?

Right-handed Left-handed Neither/Unsure

Which area of the body is affected?

Head or Neck

Shoulder or arm

Hand, wrist, or fingers

Back or hip

Leg or foot

Which side is affected?

Left side only Right side only Both, left side is worse Both, right side is worse Both, equal on both sides Not Applicable

Describe the location of your symptoms, be specific

Describe the other symptoms

How long have you been experiencing your symptoms?

How would you describe your pain? Select all that apply

Dull

Aching

Cramping

Sharp

Burning

Radiating

Unsure

Since it first started, how have the symptoms changed?

Improving Getting worse About the same Variable

Was there an injury or accident that might have caused this issue?

Yes No

What was the injury or accident? Please describe in detail

When did this injury or accident occur?

Have you had similar issues before?

Yes No

Describe when you previously had this issue

What makes your symptoms worse? Select all that apply

Repetitive motions (such as typing)

Lifting heavy items

Driving

Resting

Stretching

Sports or exercise

None

Do you use any of these mobility aids?

Cane

Crutches

Walker

Wheelchair

Mobility scooter

None

Treatments

Describe the other treatment you had

How long have you been in physiotherapy?

What kind of injection did you receive, and at what clinic did you receive this injection?

How did the treatment(s) affect your symptoms?

Have you seen other doctors/specialists for your current issue or other ongoing issues?

Yes

Please list the other specialists you have seen and the date you last followed up with them

Tests performed

Have you had any of the following tests for this issue?

X-ray

Ultrasound

Electromyograph/Nerve Study

MRI

Nuclear bone scan

None

If you have the reports, you can upload them here (not required)

Add file

Please upload a file

If you don't have the report, do you know the results of the tests?

Medical / Social History

Do you take any prescribed medications?

Yes No

List medications you currently take

Alternatively, you can upload a medication list as a file or photo below

Upload a medication list

Add file

Please upload a file

List any drug allergies you have

List any past and current medical conditions you have

List past surgeries and years

Do you smoke?

Yes No

How many cigarettes / packs do you smoke per day or week?

Do you drink alcohol?

Yes No

How many alcoholic beverages do you drink per day or week?

Living Situation

What kind of housing do you live in? (i.e. house, condo, basement)

Number of floors

Do you live alone? If not, who do you live with?

Do your symptoms make it difficult to do these activities? Select all that apply

Work/school

Sleeping

Eating

Dressing

Hygiene

Daily chores

Driving

Hobbies or sports

What is your work situation? Select all that apply

In school

Working as usual

Modified duties

Reduced hours

Unable to work

Receiving ODSP

Not working for unrelated reasons (i.e. retired)

Please write any additional information or context regarding your issue here

Feedback (optional)

Was this form easy to understand?

Yes No, I had trouble understanding some questions

Which questions were hard to understand?

Did the questions cover the details of your issue and history?

Yes No, there were details I wanted to mention not covered by this form

Additional details

Thank you for your time. The information you provide will allow us to focus on the issues affecting you the most. Our privacy policy can be read here.

Your information will be encrypted.

New Patient Intake Form

Please note: This form is only for patients who have been referred by a family physician.

Patient Information

Symptoms

Treatments

Tests performed

Medical / Social History

Living Situation

Feedback (optional)

Please note: This form is only for patients who have been referred by a family physician.

Dr. Daniel Somogyi

Physiatrist