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Services
Physiotherapy treatment
About

Services
Physiotherapy treatment
About

Pre-meeting form

Please fill out this form before your first teleconsultation meeting.

First name

Name

Date of Birth

Occupation

Address

Cell phone)

Home telephone)

E-mail

Are you currently seeing one of the following practitioners:

Doctor chiropractor Osteopath none of the above

Do you suffer from any of the following illnesses:

No known disease Cancer High blood pressure Diabetes Epilepsy Cardiac problem stomach problem Presence of metal, Pacemaker circulatory problem Chemical dependency (drug or other) Hypoglycated, ie Thyroid gland problems Emphysema/Bronchitis Asthma Migraine Rheumatoid arthritis Multiple sclerosis Depression Other arthritis conditions Cerebrovascular accident Hepatitis Anemia kidney disease HIV (AIDS) Osteoporosis allergies Others

If YES to CANCER, which one:

If YES to ALLERGIES, which ones:

If YES to OTHER:

Has your weight been stable for the past 6 months?

Indicate any surgery or other condition for which you were hospitalized, mentioning the APPROXIMATE DATE, as well as the reason for surgery or hospitalization.

Indicate any injury for which you have been treated (including fracture, sprain) mentioning the APPROXIMATE DATE

What NON-PRESCRIPTION medications are you taking or have you taken in the last week

What PRESCRIBED medications are you taking or have you taken in the last week

I authorize my physiotherapist to carry out the necessary assessments and follow-ups to improve my condition.

I authorize the sharing of information between the various stakeholders involved in my case (doctor, physiotherapist, massage therapist, osteopath, if applicable).

I authorize my physiotherapist to consult the imaging reports (MRI, X-ray, etc.), post-operative protocol or others in order to be able to adapt my treatments.

I authorize my physiotherapist to send the reports to the people involved in my case (doctors, specialists, other therapists).

Acceptance of the transmission of the medical file

I accept the transmission of the personal information above. If I wish to cancel my appointment, I will do so at least 24 hours in advance.

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Services

Postural rehabilitation
Yoga classes
Ergonomics at work
Perinatal exercises
group training

About

Physiotherapy treatment

Jaw pain (TMJ)
Myofacial tension and pain
Cervical/back/lumbar pain
Foot pain
Chronic pain
Musculoskeletal injuries
Concussion (TCCL)

Contact information

28 Avenue Saint Patrick Suite VIII (upstairs)
Gaspe, Quebec, Canada
G4X 2Y2

Telephone : (514) 791-6952
E-mail : info@zenequilibre.com
Make an appointment on Gorendezvous.com

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