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Physiotherapy Intake Form - Middlesex Spine and Sport Clinic

Physiotherapy Intake Form - Middlesex Spine and Sport Clinic 2026

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The document is a comprehensive patient information and case history form for Middlesex Spine & Sport Clinic. It collects personal details, previous health care history, chief complaints, medical doctor information, and social habits. The form also includes sections for health history, family history, and objectives for seeking physiotherapy. Patients are required to provide consent for treatment and acknowledge their responsibility for charges related to their visit.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out your personal information, including your name, address, date of birth, and contact details. This section is crucial for establishing your identity and ensuring effective communication.
Next, provide details about your previous health care experiences. Indicate if you have had physiotherapy before and include emergency contact information.
In the Chief Complaint section, describe your primary complaint and any other issues. Be specific about the nature of your pain and its duration to help the physiotherapist understand your condition better.
Complete the Health History section by checking off any relevant medical conditions or past illnesses. This information is vital for tailoring your treatment plan.
Finally, review all sections for accuracy before signing at the bottom. Your signature confirms that you understand the potential benefits and risks associated with physiotherapy.

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