Shockwave Intake form - Kelowna Shockwave

Shockwave Client Intake Questionnaire

Thank you for your interest in shockwave treatment. Please complete the following questionnaire to help us determine the most effective treatment plan for your needs.

SECTION 1: Personal Information

Name

First

Last

Age

Your preferred means of communication

Email
Phone

SECTION 2: Medical History

Have you ever received shockwave before?

Yes
No

Please briefly describe the condition or injury you're seeking treatment for

How long have you experienced this condition?

Rate your current pain or discomfort level (1 = Minimal Pain, 5 = Severe Pain)

Have you seen a physician or specialist regarding this issue

Yes
No

Have you had any imaging tests (X-ray, MRI, Ultrasound)?

Yes
No

Do you currently take any medications (including over-the-counter pain relievers)?

Yes
No

Do you have any of the following medical history?

I have a known bleeding disorder (e.g. hemophilia, low platelets)
I currently have or have had blood clots (e.g. DVT, pulmonary embolism)
I am currently undergoing treatment for cancer
I am pregnant or suspect I may be pregnant
I have an implanted pacemaker or other electronic device
I have had a surgical procedure within the last 12 weeks
Other (please specify)
None of the above apply to me

there means describe

Do you currently live with any of the following chronic health conditions?

Diabetes
High blood pressure (hypertension)
Arthritis or joint degeneration
Asthma, COPD, or other respiratory conditions
Heart disease or circulation problems
Autoimmune disorders (e.g., MS, lupus, rheumatoid arthritis)
Chronic fatigue or fibromyalgia
Other (please specify)
No chronic conditions

SECTION 3: Treatment Goals

What are your goals for shockwave treatment? (Check all that apply)

Are there activities or movements you currently cannot do because of this condition?

Do you have any concerns or questions about shockwave?

SECTION 4: Consent to Treatment

Do you agree?

I Agree

Thank you for choosing Kelowna Shockwave. By booking an appointment and using our services, you agree to the following terms:

Appointments:
All appointments must be scheduled in advance using our online booking system. You can book directly at kelownashockwave.ca/booking. No phone call or email is required.

Cancellations and Rescheduling:
You may reschedule or cancel your appointment at any time through the Customer Portal link provided in your booking confirmation email. We ask that any changes be made at least 12 hours prior to your appointment to avoid disrupting scheduling.

Late Arrivals and No-Shows:
Clients arriving more than 10 minutes late may have their session shortened or rescheduled depending on availability. Missed appointments without prior notice may be subject to a cancellation fee.

Payment:
Payment is pre-authorized at the time of booking and will only be charged after your session is completed. We accept all major credit cards through our secure online system. No charges will be applied if you cancel or reschedule within the allowed time.

Scope of Practice:
Shockwave is a non-invasive treatment intended to support musculoskeletal recovery. The service is provided by a trained technician and is not a substitute for medical diagnosis or treatment. Clients should consult their physician for any medical concerns.

Consent to Treatment:
By proceeding with treatment, the client confirms they understand the purpose, potential benefits, and possible discomforts of shockwave and consent to receive it from a trained technician.

Results Disclaimer:
While many clients experience relief from symptoms, results vary depending on the individual condition and response to treatment. No specific outcome is guaranteed.

Privacy:
All personal information collected during the booking and treatment process is kept strictly confidential and used only for the purposes of providing shockwave services. We do not share or sell your information.

Client Responsibility:
Clients are responsible for providing accurate health information, following pre- and post-treatment instructions, and ensuring they are available at their scheduled appointment time.

Service Area:
Mobile treatments are available within Kelowna, West Kelowna, Vernon, and Lake Country. Requests outside these areas are subject to availability.

Age Policy:
Shockwave is available to individuals aged 18 and over. Clients under 18 must have a parent or guardian present and provide written consent prior to treatment.

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