416-324-2240
890 Yonge St.
Suite 600
(Yonge & Davenport)
Click here for
map & parking

New Patient Information Form

Please fill in the following form and we will get back to you within 1-2 working days.

Date:

DOB: Month Day Year

Last Name: First Name:

Street Address: Apt No:

City: Province: Postal Code:

Home Phone: Bus Phone:

Cell Phone:

Best number to reach you: H W C

Email:

How did you hear of Procare Rehabilitation? (Please include name)

Doctor/Specialist

Medical Professional

Yellow Pages

Internet

Patient

Friend/Relative

Association

Insurer

Other

Questions to Think About for the Assessment

1. On a scale of 1-10, how would you rate your pain on average. (10 being the worst pain you have ever experienced)?

2. What activities are interfering with your everyday life such as walking, prolonged sitting, reaching in back pocket (10 being the worst pain you have ever experienced)?

Activity 1

Activity 2

Activity 3