Emergency Contact Name: Phone:

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1 Name on Care Card Preferred Name Phone ( ) -- Home/Cell/Work Phone( ) -- Home/Cell/Work for appointment reminders/communication/newsletter: (by providing an I consent to Parkway s use of that in communication) Care Card Number Date of Birth / / MonthDay Year Address: City Post Code Parkway has a 24 hour notice cancellation policy for your reserved space, for failing to observe this policy you may incur a $25 reservation fee. Providing the following information is interpreted as consent to share details pertinent to your case with those individuals mentioned below and is in force for 2 years. ** For the protection of your privacy, revocation of this given consent is preferred in writing** Signed Date(M) /(D) /(Y) Referring Doctor (first name) (last name) Family Doctor (first name) (last name) Emergency Contact Name: Phone: All Services are paid directly by the patient unless a third party funder provides coverage. A user fee applies to all MSP and ICBC visits and is due at the time of service. Worksafe BC Only --Please provide all information below as it is required to bill Worksafe BC on your behalf. Date of Injury (M) /(D) /(Y) Claim #_ Referring Doctor Employer Name Company and telephone contact # Case Manager Phone( ) -- Case Manager Phone( ) -- ICBC only-- Please provide all information below as it is required to bill ICBC on your behalf. Date of Accident (M) /(D) /(Y) Claim #_ Where you a pedestrian/cyclist or passenger in this accident? Yes/No Are you currently attending massage therapy under this claim? Yes/No Adjuster_ Phone( ) -- Lawyer (?) Phone( ) -- MSP Premium assistance (Care Card will be verified) I wish to assign all reimbursements for benefits payable to me to Parkway Physiotherapy + Performance Centre for care provided to me. I am aware that I am responsible for all outstanding balances. Signed Date(M) /(D) /(Y)

2 Occupation Female Symptom Monitor Presenting problems When did this start? Please fill out each section that is relevant to your problem Gynecological History What age did your period start? Is your cycle regular? How long is your cycle? Do you suffer from PMS? Is your bleeding heavy? Do you have pain with your period? If yes, when? Do you use tampons? Do you have pain with insertion of a tampon? Do you have excessive discharge? Sexually active? Birth control? Type: Pain with intercourse? # of pregnancies # of live births Wt. heaviest baby lbs oz Length pushing stage hours # of C- sections # of vaginal deliveries Did you have an epidural? Did you have a vacuum- assisted delivery? Forceps? Episiotomies? Tears? During my labour(s) and delivery, I felt supported and cared for: o All or most of the time o Some of the time o A little bit t at all Were there times during labour and delivery that you were (or thought you were) in danger of death or injury? Were there times when the baby was or seemed to be in danger during labour and delivery? Do you suffer/have you suffered from post- partum depression? Have you gone through menopause? If so, when? Do you suffer from vaginal dryness? Hormone replacement therapy If yes, what? Do you use lubrication? Sometimes What type: 1

3 Do you have feelings of heaviness/pressure in your vagina? Have you ever been told you have a prolapse? Have you had any of the following medical procedures? If so, please provide approximate date: Appendectomy Bartholin Cyst Bowel resection Laparoscopy Cystoscopy Colostomy TVT- TVT(O) Gallbladder removal Hemorrhoid surgery Mesh procedure Prolapse/Vaginal repair Hysterectomy Other Bladder Symptoms Did you have problems with your bladder during childhood? o Sometimes Do you have leakage associated with sneezing, coughing, running and/or o Sometimes laughing? Do you have leakage during intercourse? o Sometimes Do you feel really strong sensations prior to voiding but don t leak? o Sometimes Does your leakage occur after having a strong urge that feels o Sometimes uncontrollable? Do you have pain when your bladder fills? o Sometimes Does your pain improve when you void? o Sometimes Do you have pain when you void? o Sometimes Do you have to strain in order to empty your bladder? o Sometimes Do you have difficulty starting your urine steam? o Sometimes Do you have dribbling after you get up from the toilet? o Sometimes Do you sit on the toilet? o Sometimes Do you have incomplete emptying when you void and feel like you have to o Sometimes go again soon? Do your bladder problems cause you to leak at night? o Sometimes Does your incontinence fluctuate with your cycle? o Sometimes 2

4 Does your incontinence require you to wear pads? o Sometimes If you answered yes or sometimes, how often? Do you void during the day more than the average person (5-7x/day)? o Sometimes If you answered yes or sometimes, how often? Do you need to get up at night to void? o Sometimes If you answered yes or sometimes, how many times? Fluid intake in 24 hours # cups of water/day # cups of coffee/day # cups of tea/day # cups of other fluids/day # alcoholic drinks/day Digestion & Bowel Function What is the frequency of your bowel movements? Do you regularly feel the urge to move your bowels? o Never o Seldom o Always Do you have constipation? o Always o Seldom o Never Do you strain to have a bowel movement? o Always o Seldom o Never Do you have loose stools/diarrhea? o Always o Seldom o Never Do you have bowel urgency that is difficult to control? o Always o Seldom o Never Do you lose control of your bowels? o Always o Seldom o Never Do you have incomplete emptying? o Always o Seldom o Never Do you have pain with a bowel movement? o Always o Seldom o Never Do you have pain after a bowel movement? o Always o Seldom o Never Does it take longer than 5 minutes to have a bowel movement? o Always o Seldom o Never Do you have bloating? (Increased pressure in abdomen) o Always o Seldom o Never Do you experience a physical change in abdominal girth when your bowels are full (distension)? o Always o Seldom o Never In your opinion, is your fibre intake o Too low o Adequate o Too high Do you regularly use o Laxatives o Stool softeners o Natural products o Enemas Have you ever been diagnosed with/think you have: Irritable bowel syndrome When? Who? Ulcerative colitis When? Who? Crohn s Disease When? Who? Celiac Disease When? Who? 3

5 Do you have any food allergies or sensitivities? Medical History Urinary tract infections How often? Antibiotics recently? Last UTI? Probiotics? Cranberry supplementation? Smoking # packs/day Chronic cough Yeast infections How often? Last infection Treatment Do you get blood in your urine? Allergies (including latex): Do you exercise? Type: Frequency: Low back problems Chronic? Mid back problems Chronic? Neck problems Chronic? Have you ever been treated for depression? What treatment? Is/was treatment effective? Have you ever been treated for anxiety? What treatment? Is/was treatment effective? On a scale from 1-10, please circle and rate how much this problem bothers you On a scale from 1-10, please circle and rate how motivated you are to correct this problem

6 DASS Questionnaire Please read each statement and circle a number, o, 1, 2, or 3, which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. S = A = D = 0 = It did not apply to me at all 1 = Applied to me to some degree or some of the time 2 = Applied to me a considerable degree, or a good part of the time 3 = Applied to me very much, or most of the time I find it hard to wind down S I was aware of dryness of my mouth. A I could not seem to experience any feeling at all. D I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion. A I found it difficult to work up the initiative to do things. D I tended to over- react to situations.. S I experienced trembling (e.g. hands) A I felt that I was using a lot of nervous energy S I was worried about situations in which I might panic and make a fool of myself.. A I felt that I had nothing to look forward to.. D I found myself getting agitated. S I found it difficult to relax. S I felt down- hearted and blue. D I was intolerant of anything that kept me from getting on with what I was doing. S I felt I was close to panic.. A I was unable to become enthusiastic about anything.. D I felt I was not much of a person. D I felt that I was rather touchy S I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) A I felt scared without any good reason. A I felt that life was meaningless. D