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Victoria Szwajcer
Reg PT , RYT
Physiotherapist & Yoga Therapist
www.rehabyoga.ca

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unfurled fern represents new life and new beginings

Physiotherapy Intake Form:

Please fill out the following form prior to your initial Assessment with Victoria Szwajcer PT:

Date

First name

Email

Have you ever been treated for or had one of the folowing? Heart Trouble:

No

Yes

Lung Condition

Yes

No

Osteoarthritis

Yes

No

Multiple Sclerosis

Yes

No

Last name

Date of Birth

Cancer

Yes

No

High Blood Pressure

No

Yes

Rheumatoid Arthritis

Yes

No

Stroke

Yes

No

Diabetes

Yes

No

Hepatitis

Yes

No

HIV

Yes

No

Other

Please elaborate here, also can use space to let me know what your goals of therapy are:

Street Address

City

Province

Postal code

I declare that the info I’ve provided is accurate & complete

Your Signature

Thanks for submitting!

unfurled fern, represent new begining, metaphor to starting rehabilitation

Easy Payment :

Physiotherapy Receipts will be provided for physiotherapy services and regular receipts provided for classes

Physiotherapy Assessment payment $150

Physiotherapy Treatment payment $130

Zumba class pass $20 (4 classes)

Adapted Yoga class pass $84 (6 classes)

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Victoria Szwajcer Reg PT , RYT Physiotherapist & Yoga Therapist www.rehabyoga.ca

Physiotherapy Intake Form:

Easy Payment :

Physiotherapy Receipts will be provided for physiotherapy services and regular receipts provided for classes

Victoria Szwajcer
Reg PT , RYT
Physiotherapist & Yoga Therapist
www.rehabyoga.ca