Maria Etkind-Shafrir - Client Package.pdf

7/17/2019 Maria Etkind-Shafrir - Client Package.pdf

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INTAKE

QUESTIONNAIRE

Name: ______________________________________________ Date : ____________________________________________

Date of birth: ________________________________________ □ Male □ Female

MM/DD/YY

MM/DD/YY

GENERAL INFORMATION

□ New patient

How did you hear about our clinic?

□ Family physician

□ Insurance company

□ Workers insurance

□ Employer

□ Specialist

□ Rehab case manager

□ Other CBI clinic

□ Self referral

□ Friends/Family ___________________________________

□ Internet

□ Print advertisement (newspaper/magazine)

□ Yellow Pages book advertisement

□ Yellow Pages online advertisement

□ Search engine (Google, Yahoo, Bing, etc...)

□ Promotional activity

□ Sports club/community group

□ Radio/TV

□ Other __________________________________________

□ Return patient

□ Same episode □ Recurrence □ New episode

What is your primary reason for returning to our clinic?

□ Specic clinician

□ Overall quality of care

□ Treatment approach

□ Clinic location

□ Ease of access (parking, hours)

□ Appearance of the facility

□ Access to exercise equipment

□ Other __________________________________________

↓ ↓ ↓ ↓

What do you expect from your treatment at our clinic? (select as many as applicable)

□No more pain

□Improvement with activities

□Increased strength

□Return to work

□ Other __________________________________________

EMAIL NOTIFICATION

I agree to receive e-mail notications regarding the following: appointment reminders/scheduling changes, newsletters, education

materials/injury prevention information and information on our services. I understand that I may opt out at any time by unsubscribor by informing CBI that I no longer wish to receive email notications.

E-mail address: _____________________________________ □ Check box to opt in Initials: ________________________



1. Has your doctor ever said you have heart trouble ?

3. Do you ever feel faint or have spells of severe dizziness ?

4. Have you ever had a seizure ? ……………………………………..

2. Do you frequently have pains in your heart or chest ? …………..

5. Have you ever been told that your blood pressure is too high ?

6. Do you experience difficulty breathing when resting ? ………….

7. Do you have a history of asthma, emphysema or COPD ? …….

8. Do you have a persistent cough ? ………………………………….

9. Have you had a recent viral infection ? …………………………….

10. Have you had any surgery in the past twelve (12) months ?

CBI Health Screen - page 1

Date of injuryte of birth

me:

ease answer the following questions ( your responses will be kept completely confidential)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Male

Female

Date

Health Screen p1: 5

. o you ave any pro ems w swe ng n your egs or ee es o

12. Are you currently on any medication ? …………………………… Yes No

List all the PRESCRIBED

medications you are taking Prescribing physicianDosage

13. Is there any medication you are supposed to be taking that you are

not taking ?

Yes No

14. If female, are you pregnant ? …………………………………………….... Yes No

15. Is there a good physical reason, not mentioned here, why you should

NOT follow an activity/exercise program ?

Yes No

Prescribing physician’s phone numb

List all the

herbal/homeopathic/naturopathic

products you are takingDosage

List all the over-the-counter

(non-prescribed)

medications you are taking Dosage

(continued on page 2)



19. Diabetes ? …………….............................................

21. Bowel problems ? ……………………………………..

22. Bladder problems ?

20. Metal pins, plates, or screws inserted into a bone ?

23. Rheumatoid arthritis ? ………………………………...

24. Epilepsy ?

25. Current fatigue or nausea ? ………………………..

26. Blackouts ?

27. Circulation problems ? ………………………………..

28. Cancer (past or present) ?

CBI Health Screen - page 2

me:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Date of birth

29. Pace maker ? …………………………………………. Yes No

Please indicate if you have any of the following:

16. Have you ever been diagnosed with depression or anxiety ? Yes No

17. Has stress negatively affected your work-life balance in the past 6 months ?

(for example, time off work or illness)

Yes No

18. Have you experienced a significant weight loss or gain in the past 60 days ? Yes No

30. Blood clots ? Yes No

31. Osteoporosis ? ………………………………………... Yes No

32. Any other condition(s) not listed ? Yes No

33. Do you have any allergies ? ………………………… Yes No

If Yes, please provide details: _______________________________________________

If Yes, please provide details: _______________________________________________

_______________________________________________

Emergency phone:Emergency contact:

In case of a medical emergency, do you have any special instructions for your therapist? Yes No

If Yes ____________________________________________________________________________________________________

Follow up with physician if necessary:

Therapist name: _____________________________ Date of call: _____________________

Physician comments:

or office use only:

Resting heart rate ___________________________ Blood pressure __________________

s very important that you provide accurate responses to this questionnaire.

owingly withholding and/or providing inaccurate medical information can negatively affect any treatment or recommendations that CBI healt

ght give you.

the best of my knowledge, I certify that the information given is accurate. _________________________________________________

Client Signature

Health Screen p2: 5



Effective (2013-06-01)FSCO(1224E.2)

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Warning – Offences

It is an offence under the Insurance Act to knowingly make a false or misleading statement or representation to an insurer in connection

with the person’s entitlement to a benefit under contract of insurance. The offence is punishable on conviction by a maximum fine of$250,000 for the first offence and a maximum fine of $500,000 for any subsequent conviction.

It is an offence under the federal Criminal Code for anyone to knowingly make or use a false document with the intent it be acted on asgenuine and the offence is punishable, on conviction, by a maximum of 10 years imprisonment.

It is an offence under the federal Criminal Code for anyone, by deceit, falsehood or other dishonest act, to defraud or to attempt todefraud an insurance company. The offence is punishable, on conviction, by a maximum of 10 years imprisonment for fraud involvingan amount over $5,000 or otherwise a maximum of 2 years imprisonment.

Incomplete or incorrect information may result in your application being denied.

Accident BenefitsApplicationPackage

About this Application for Accident Benefits

Please note that all automobile accidents involving bodily injury must be reported to the police. Claims forcertain accident benefits must be made within 7 days. Please contact your adjuster for further information.

There are five forms in this package:

■ Application for Accident Benefits (OCF-1)

Fill out this form when you are applying for benefits for the first time as a result of an accident,including if you are injured and are applying for income replacement benefits. You may be eligible forweekly benefits even if you were unemployed or retired at the time of the accident.

This Application for Accident Benefits form must be returned within 30 days after receiving thepackage. If you are unable to return it within 30 days, submit it to your insurance company anywayand explain why you were not able to complete it within 30 days. Return the original form to theinsurance company and make a copy for your records.

■ Employer’s Confirmation of Income (OCF-2)

If the insurance company asks you to, please give this form to your employer. This form is completedby you or your representative and by your employer. If you had more than one employer during thepast 52 weeks, it is necessary for each employer to complete a separate form. Your insurancecompany may ask for other proof of income.

■ Disability Certificate (OCF-3)

If the insurance company asks you to, please fill out the first section and give this form to your healthpractitioner (chiropractor, dentist, occupational therapist, nurse practitioner, optometrist, physician,physiotherapist, occupational therapist, speech language pathologist or psychologist). This form iscompleted by you or your representative and by your health practitioner.

■ Permission to Disclose Health Information (OCF-5)

If the insurance company asks you to, please complete this form. The insurance company requiresyour medical information in order to correctly determine your eligibility for benefits. Healthprofessionals require your written permission to disclose this information to the insurance company.

■ Treatment Confirmation Form (OCF-23)

This form must be completed to confirm treatment received under the Minor Injury Guideline foraccidents which occurred on or after September 1, 2010, or the Pre-approved Framework Guidelinefor accidents which occurred prior to September 1, 2010. There are exceptions. Please contact yourinsurance company to find out if this form is required.

After the insurance company reviews your complete application package, you will be contacted about thebenefits you are entitled to receive. If your insurance company needs any additional information in order toprocess your application, they will contact you.

Use this package to apply for benefits if you were injured in anautomobile accident on or after November 1, 1996.

© Queen's Printer for Ontario, 2013

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Where do I send the Application Forms?Please follow the instructions below.

1. If You Own, Lease, or Have Regular Use of a Company Automobile

As of the date of the accident did you, your spouse or someone you are dependent on (please check all the

options that apply to you):

Own an automobile?

Lease or have a contract to rent an automobile for more then 30 days?Drive a company automobile which was made available for your regular use?

Yes - If you checked only one, send the forms to the insurance No - If none apply, continue to 2.company that insures this automobile.

Yes - If you checked more than one, send the forms to theinsurance company of the vehicle in which you were anoccupant at the time of the accident.

Yes - If you checked more than one and were not an occupantin either of the automobiles, send the forms to the insurerof either vehicle (you choose).

2. If You are a Listed Driver

Are you listed as a driver on somebody’s insurance policy?

Yes - If yes, send your forms to the insurance company that No - If no, continue to 3.issued the policy you are listed on.

The following categories only apply if:

• You, your spouse or someone that you are dependent upon does not own, lease, or regularly usea company automobile.

• You are not listed as a driver on a policy.

3. Occupant of Somebody Else’s Automobile

Were you an occupant of somebody else's automobile that was insured at the time of the accident?

Yes - If yes, send your forms to the insurance company that No - If no, continue to 4.insures this automobile.

4. Pedestrian or Bicyclist

Were you a pedestrian or a bicyclist struck by an automobile that was insured at the time of the accident?

Yes - If yes, send your forms to the insurance company of No - If no, continue to 5.the automobile that struck you.

5. Uninsured Automobile

Were you an occupant of an automobile that was not insured at the time of the accident?

Yes - If yes, send your forms to the insurance company of any No - If no, continue to 6.

other automobile that was involved in the accident.

6. None of the Above Apply

If you do not have automobile insurance and no other automobile involved in the accident either has automobile insuranceor can be identified, you may be entitled to obtain accident benefits from the Motor Vehicle Accident Claims Fund. Pleasecomplete the entire application package and see Part 10.


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Return this form to:

Application for AccidentBenefits (OCF-1)

Use this form for accidents that occur on or after November 1, 1996.

Claim Number:

Policy Number:

Date of Accident:(YYYYMMDD)

A separate form must be completed for each person who is applying for accident benefits. Completion of ALL sections is mandatory. Yourapplication may be denied if information is incomplete or incorrect. Please print clearly.

Part 1ApplicantInformation

Last Name GenderMale Female

Marital Status

SingleMarriedCommon-law

SeparatedDivorcedWidow(er)

First Name and Initial Birth DateYear Month Day

Address Is anyone dependant on you forfinancial support or care?

City Province Postal Code Yes, how many persons?

No

Home Telephone Work Telephone Fax Number

You can be reached: Language Spoken: What is the best time to reach you:by telephoneby personal visit

at homeat work

Day(s) of the week

E-mail: Time of day a.m.

other p.m.

Part 2Applicant’sRepresentative(if applicable)

Complete this section only if the applicant injured in the accident is deceased, is a minor, is unable to fill out the form ontheir own, or has retained you as their representativeLast Name Relationship with applicant

Parent Guardian

First Name and Initial Lawyer OtherOther Paid Representative

Address

City Province Postal Code

Work Telephone Fax Number E-mail:

Part 3AccidentDetails andHealthInformation

Date of Accident

Year Month Day Time of Accident

a.m. You were a:

Driver Pedestrian

p.m. Passenger Other

Accident Location: Hwy. No./Street Name City Province

Did the accident occur while you were at work? Yes No

Did you file a claim with the Workplace Safety and Insurance Board? Yes No

Was the accident reported to the police? Yes (Give details below) No

Officer Name Badge No. Date accidentreported to the police

Year Month Day

Police Department/Collision Reporting Centre

Were you charged? No Yes (Give details)

Give a brief description of the accident. If you suffered any injuries as a result of the accident, describe the cause and extent of the injuries.

Were you able to return to your normal activities following the accident? Yes No

Did you go to the hospital? Yes (Give details) No

Did you go see a health professional? ( for example: physician, chiropractor, physiotherapist?) Yes (Give details) No

Additional sheets attached


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Part 3AccidentDetails andHealthInformation(cont’d)

Name of Health Professional Name of Facility

Address

City Province Postal Code

Has this Health Professional begun any treatment? Yes (provide details) No


Part 4Details ofAutomobileInsurance

In order to determine which automobile insurer is responsible for paying benefits, it is necessary to know whether you haveyour own policy or whether you are covered by somebody else's insurance policy. To help make that determination, please

complete the following:

A Are you covered under any of the following automobile insurance policies?

Your own policy Yes No

Your spouse's policy Yes No

The policy of any person on whom you are dependent (e.g. a parent) Yes No

A policy that lists you as a driver (e.g. a friend) Yes No

Your employer's policy (e.g. company car) or spouse's employer's policy Yes No

A policy insuring long-term rental cars (for rentals exceeding 30 days) Yes No

If you answered “No" to all of the above, go to B If you answered "Yes" to any of the above, complete the following:

Name of Policyholder

Insurance Company Policy Number

Automobile – Make, Model, Year Licence Plate Number

Were you an occupant of this automobile at the time of the accident? Yes No

If you answered “Yes” to more than one box in this part, provide additional insurance details below.

Name of Policyholder


Automobile – Make, Model, Year Licence Plate Number

Were you an occupant of this automobile at the time of the accident? Yes No

B If you checked "No" to all of the boxes in A you must send your application to the insurer of the automobile that youoccupied at the time of the accident, or the vehicle that struck you if you were a pedestrian or bicyclist. If this automobilewas not insured or was unidentified, describe any other vehicle involved in the accident. Provide details below.

The policy you are claiming under insures: Vehicle type covered by this policy:

The vehicle I was riding in at the time of the accident Passenger Truck

The vehicle that struck me as a pedestrian/bicyclist Motorcycle Bus

Another vehicle that was involved in the accident Taxi/Limousine Snowmobile

Other

Owner of the Vehicle Home Telephone

Address Work Telephone

CityProvince Postal Code

Automobile – Make, Model, Year


Name of Policyholder Licence Plate Number

Did you report the accident to any other insurance company? Yes (provide details) No

Insurance Company Type of Insurance


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Part 5ApplicantStatus

Which of the following describes your status at the time of the accident?

Employed Not Employed

Employed and working Unemployed Student or recent graduate

Self-Employed Unemployed and,

have worked 26 weeks in the past 52 weeks

receiving Employment Insurance Benefits

Retired Caregiver

Part 6

StudentAttendingSchool

Were you attending school on a full-time basis at the time of accident or had you completed your education lessthan one year before the accident?

Yes (Give details below) No (Continue to Part 7)

Name of SchoolDate Last Attended

Year Month Day

Address Program and Level

City Province Postal Code Projected Date forCompletion of Studies

Year Month Day

Are you now attending school? Yes (Enter date)Year Month Day

| | | | | | | No

Were you able to return to school after the accident? Yes (Enter date) Year Month Day

| | | | | | | No

Part 7Caregiver

Were you the main caregiver to people living with you, at the time of the accident?

Yes (Complete information below) No (Continue to part 8)

Were you paid to provide care to these people? Yes (Continue to part 8) No

List the people who you were caring for at the time of the accident

NameDate of Birth Disabled

Year Month Day Yes No


Did your injuries prevent you from performing the caregiving activities you did prior to the accident?

Yes (Explain below) From what date? Year Month DayNo

Explanation:


At any period since the accident, were you able to return to caregiving?

Yes (From what date?) Year Month Day

No


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Part 8IncomeReplacementDetermination

Give details of your employment for the past 52 weeks. Start with your current or most recent employer. If you held morethan one position with the same employer, use a separate line for each position. Gross income is before taxes anddeductions.

If you were self-employed during the 4 weeks prior to the accident, please consider yourself the employer for thepurpose of completing this section.

DateYear/Month/Day

Name and Addressof Most Recent Employer

Position/EssentialTasks

No. of HoursPer week

Gross Incomefor the period

From:

To:

$

From:

To:

$

From:

To:

$

From:

To:

$


Did your injuries prevent you from working?

Yes (From what date?) Year Month Day

No (Continue to Part 9)

At any period since the accident, were you able to return to work since the accident?

Yes

(From what date?)

Year Month DayNo

The amount of your benefit is based on your past income. During which of the following periods did you have the highest average weekly

income?

Last 4 weeks (not applicable for sel f-employed persons)

Last 52 weeks

Last fiscal year (self-employed only)

Part 9OtherInsurance orCollateralPayments

Do you, your spouse or anyone you are dependent on (eg. parents) have any other benefit plan that covers you (e.g., groupor private, union, disability, medical or dental, etc.)?

Yes (Give details below) No

Name of Benefit Payor Type of Coverage Policy or Certificate Number

During the past 52 weeks, did you receive any income from a disability plan? Yes (Enter dates) No

From: Year Month Day To:Year Month Day

Total AmountReceived

$

Are you receiving Employment Insurance Benefits? Yes (Enter date) No

From: Year Month Day To:Year Month Day

Total AmountReceived

$


Are you receiving Social Assistance Benefits (welfare)? Yes No


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Part 10Motor VehicleAccidentClaims fund

DO NOT FILL OUT UNLESS ITEMS (1) TO (5) ON PAGE 2 DO NOT APPLY AND YOU ARE APPLYING TO THEMOTOR VEHICLE ACCIDENT CLAIMS FUND

You and your representative acknowledge that you have the responsibility to investigate and apply to all potentialinsurers to which the applicant may have recourse BEFORE submitting an application to the Motor Vehicle AccidentClaims Fund (MVACF).You and your representative acknowledge that the application MUST INCLUDE a completed:

NOTICE OF COLLECTION OF PERSONAL INFORMATION FORM, signed and attached*

Form 3 – Section 6 MVACF Application for Statutory Accident Benefits, signed and attached*

Motor Vehicle Accident (Police) Report, attached.

before the applicant can make an application for the payment of accident benefits from the MVACF.(* These forms are available at www.fsco.gov.on.ca)

I certify that I have read this part and understand that this application for accident benefits is not complete until therequired forms are completed, signed and provided to the MVAC Fund.

Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date(YYYMMDD)

Motor Vehicle Accident Claims FundPO Box 855160 Yonge StreetToronto, ON M2N 6L9

Toronto calling area: (416) 250-1422Toll Free: 1- (800) 268-7188

Part 11

Signature

TO THE INSURER TO WHOM THIS APPLICATION IS BEING SUBMITTED:

I UNDERSTAND that you, and persons acting for you, will collect and use personal information and personal healthinformation about me that is related to my claims for accident benefits arising out of the accident described in thisapplication, and that all such information will be collected directly from me, or from any other person with my consent.

I ALSO UNDERSTAND that this information will be collected and used only as reasonably necessary for thepurposes of:

Investigating my claims and processing my claims as required by law, including the Ontario AutomobilePolicy;

Obtaining or verifying information relating to my claims in order to determine entitlement and the properamount of payment;

Recovering payment from insurers and others liable in law for amounts that you pay in connection with myclaims;

Identifying and analyzing the nature and costs of goods and services that are provided to automobileaccident victims by health care providers;

Preventing fraud, and detecting fraud where there are reasonable grounds to suspect fraud;

Compiling anonymized statistics for government agencies; and

Assessing underwriting risks and claims experience.

I ALSO UNDERSTAND that you, and persons acting for you, may disclose this information to the following persons,who may collect and use this information only as reasonably necessary to enable you to carry out the purposesdescribed above:

Insurers; insurance adjusters, agents and brokers; employers; health care professionals; hospitals; accountants;financial advisors; solicitors; organizations that consolidate claims and underwriting information for the insuranceindustry; and my agents or representatives as designated by me from time to time.

I CONSENT to you collecting, using and disclosing this information in the manner described above, but no more ofsuch information than is reasonably necessary to meet the legitimate purpose of such collection, use or disclosure.

I UNDERSTAND that if I have any questions about this consent I am free to consult with my insurance company

representative or legal advisor before signing this document.

I AM ALSO AWARE that you, and persons acting for you, may be required or permitted by law to disclose thisinformation to others without my knowledge or consent.

I certify that the information provided is true and correct.

I understand that it is an offence under the Insurance Act to knowingly make a false or misleading statement orrepresentation to an insurer under a contract of insurance. I further understand that it is an offence under the federalCriminal Code for anyone, by deceit, falsehood, or other dishonest act, to defraud or attempt to defraud an insurancecompany.

Name of Applicant or Substitute Decision Maker (please print) Signature of Applicant or Substitute Decision Maker Date (YYYMMDD)


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ntake Questionnaire Program Patient: Upper Extremity pain (DASH)

ame: Male

Female

DateDate of birth

Severe

difficultyMild difficultyModerate

difficulty

1. Open a tight or new jar

2. Write ……………………………………………………………………..

3. Turn a key

4. Prepare a meal ..………………………………………………………..

5. Push open a heavy door

6. Place an object on a shelf above your head .……………………….

7. Do heavy household chores (wash walls, floors)

8. Gardening or yard work ………………………………………………..

No difficulty

ease rate your ability to do the following activities in the last week:

Unable

10. Carry a shopping bag or briefcase ………………………………….

11. Carry a heavy object (over 10 lbs)

9. Make a bed

13. Wash or blow dry your hair

14. Wash your back….. …………………………………………………..

12. Change an overhead light bulb ……………………………............

15. Put on a pullover sweater

17. Light recreational activities (ex: play cards, knitting)

18. Recreation using the arm (ex: golf, tennis, hammering) ………...

19. Recreation using the arm freely (ex: frisbee, badminton)

16. Use a knife to cut food .. ……………………………………………..

20. Transportation needs (getting from one place to another)

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

21. Sexual activities …………………………………………..................

22. To what extent has your arm, shoulder or hand problem

interfered with your normal social activities with family or

friends (during the past week)

23. Were you limited in your other regular activities as a result

Quite a bitSlightly ModeratelyNot at all Extremely

25. Arm, shoulder or hand pain when performing any specific activity

26. Tingling (pins and needles) in your arm, shoulder or hand

24. Arm, shoulder or hand pain …………………………

27. Weakness in your arm, shoulder or hand

29. How much difficulty have you had sleeping because of pain in

your arm, shoulder or hand (in the past week)

28. Stiffness in your arm, shoulder or hand…………………..

30. I feel less capable, less confident or less useful because of my

arm, shoulder or hand problem

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

……………. ……………. ……………. …………….

of your arm, shoulder or hand problem (during the past week)

Please rate the severity of the following symptoms in the past week:

Severe

difficultyMild difficultyModerate

difficultyNo difficulty Unable

SevereMild ModerateNone Extreme

AgreeDisagree Neither Strongly disagree Strongly agree

No more pain

Improvement with activities

Increased strength

Return to work Other ______________________

hat do you expect from your treatment at our clinic?

elect as many as applicable)

32. Are you having t rouble at work; home; with friends (due to this injury) ? ………………

31. Is someone else primarily to blame for your situation ? …………………………………

33. Are you receiving (or anticipate receiving) financial compensation for your injury ?

34. Have you contacted a lawyer about your injury ? ………………………………………..

35. Do you think you will recover completely from your injury ? ……………………………

Yes No

Yes No

Yes No

Yes No

Yes No

gree to receive e-mail notification regarding the following: appointment reminders/scheduling changes, educational materials/injury prevention information and information on our services.

________________________________________________________________________

ovide emailaddress)

Check box to opt in ____________

(initials)

Maria Etkind-Shafrir - Client Package.pdf

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