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CLIENT INTAKE FORM

General Information

Medical Identification

Emergency Contact Information


Third Party Funding

Notice regarding payment


Örebro Musculoskeletal Screening Questionnaire

These questions and statements apply if you have aches or pains, for example back, shoulder or neck pain. Please read and answer each question. Each question needs a response.



.

Not At All

.

 Extremely


.

Not At All

.

 Extremely


.

Never

.

 All the time



Örebro Musculoskeletal Screening Questionnaire continued...2


We also need a bit more information on your thoughts and feelings. Each question needs a response.


.

Not At All

.

 Extremely


.

Not At All

.

 Extremely


.

No risk

.

 Very large risk


.

Not At All

.

 Extremely



Örebro Musculoskeletal Screening Questionnaire continued...3


How true are the next two statements for you? Each question needs a response.


.

Not At All

.

 Extremely


.

Not At All

.

 Extremely



Help us to better understand your current physical abilities. Each question needs a response.


.

Not At All

.

 Completely normal


.

Not At All

.

 Completely normal





Medical Profile


Important Information

Our practice is committed to providing you with quality, continuing care, including the protection of the confidentiality of your records. As part of this care and in compliance with the Privacy Legislation, it is important that we gain your consent to collect and use personal information about you, only as necessary. Our practice has a Privacy Policy on the collection, use, disclosure and security of information obtained from our patients.

Consent Statements
Financial Terms and Conditions
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