New Client Form

As health care professionals, our goal is to make sure you are functioning at your absolute best. As we journey towards achieving your health and fitness goals, we will not only treat the symptoms that brought you to us, but also the underlying cause. To ensure we get the optimum results we need you to answer some simple questions.

Please fill out the form as required below:

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Street Address *

Doctor's Name

Doctor's Number

Do you give permission to The Traveling Physio to contact your doctor and discuss your condition with them?

Kupat Cholim *

Private Insurance

Occupation

We like to reward and thank our clients that refer their friends and family to us. In order to do so, please let us know how you heard about The Traveling Physio:

Have you read and understand the rules and regulations and are you happy to proceed with treatment from The Traveling Physio? Please fill in your full name and ID number to confirm.

Your Symptoms

What is the major symptom you would like to address?

How did this symptom arise?

What type of symptoms do you have? (pain, stiffness etc)

Where are your symptoms? (eg headache, shoulder pain etc)

Are your symptoms constant?

How long have they been present? (hours, days, weeks etc)

Are your symptoms improving, staying the same or getting worse?

What makes your symptoms worse?

What makes your symptoms better?

Have you had symptoms in this region before? (is this the first time you have had symptoms in this area?)

If yes, have you had physiotherapy treatment before? What was involved in the treatment and was it effective?

If you have not had physiotherapy treatment before, have you received another type of therapy? What was involved in the treatment and was it effective?

Do they impede with your ability to function? (get dressed, shower etc)

Do they impede with your ability to sleep? (does it wake you up, do you need to sleep on a different side etc)

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New Client Form

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