• Part 1: CONFIDENTIAL MEDICAL QUESTIONNAIRE

      Please take a few minutes to complete this questionnaire before your appointment with the physiotherapist. The health check is for the health professional to find out about your general health and if there are any potential implications for your treatment. The information you provide is confidential and for treatment purposes only. You must click "Send" once you have completed the form.

      EXERCISE FREQUENCY

      How often do you exercise?
      NeverLess than once a week2-4 times / weekMore than 4 times / week

      What type of exercise do you do?
      WalkingRunning/JoggingGymPilates/YogaSportsOther. Please list

      MEDICAL CONDITITIONS

      Are you aware of any health problems? If yes, details?
      YesNo

      Do you have a cardiac pacemaker or metal implant? If yes, details?
      YesNo

      Have you had a stroke? If yes, details?
      YesNo

      Do you have heart problems? If yes, details?
      YesNo

      Do you suffer from high/low blood pressure? If yes, details?
      YesNo

      Do you have Diabetes? If yes, details?
      YesNo

      Do you suffer from epilepsy? If yes, details?
      YesNo

      Do you have asthma or breathing difficulties? If yes, details?
      YesNo

      Do you have or had cancer or tumour? If yes, details?
      YesNo

      Do you suffer from arthritis osteoporosis or other joint problems? If yes, details?
      YesNo

      GENERAL HEALTH

      Have you lost/gained weight in the past six months? If yes, details?
      YesNo

      Have you ever been seriously ill or had a major operation? If yes, details?
      YesNo

      Do you have any communicable diseases e.g. hepatitis A, B, C, HIV? If yes, details?
      YesNo

      Do you have any health problems that restrict your activities or day? If yes, details?
      YesNo

      Do you or have you smoked? If yes, details?
      YesNo

      Do you consume alcohol above the Governments maximum recommended amounts? If yes, details? YesNo

      Are you currently taking any prescription medication? If yes, details?
      YesNo

      Are you currently taking any non-prescription medication or remedies? If yes, details?
      YesNo

      Are you pregnant or trying to conceive? If yes, details?
      YesNo

      SIGNS AND SYMPTOMS

      Do you experience chest pain? If yes, details?
      YesNo

      Have you had episodes of shortness of breath? If yes, details?
      YesNo

      Have you had episodes of severe dizziness? If yes, details?
      YesNo

      Do you experience difficulty breathing? If yes, details?
      YesNo

      Do you experience swelling around your ankles? If yes, details?
      YesNo

      Have you ever had heart palpitations or murmur? If yes, details?
      YesNo

      Do you regularly get muscle aches in your legs when walking? If yes, details?
      YesNo

      Do you know of any reason why you should not engage in physical activity? If yes, details?
      YesNo

      Part 2:CONFIDENTIAL PATIENT CASE HISTORY

      As a physiotherapy practice providing comprehensive care, we focus on your ability to be healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly, to treat the cause of your condition (not just treat the symptoms or place a temporary patch over your condition); and thirdly, to offer you the opportunity of improved health potential and wellness services in the future. Answering the following questions will give us a profile of your health, and ensure that we make the most of your appointment time and optimise your outcome and deliver physiotherapy excellence.

      What is your major complaint?

      How long have you had this problem?

      Did you have a sudden onset and if so why?

      Have you had this or similar problem in the past?

      What made you choose us to help with your problem?

      If you are experiencing pain, please tick the words that best describe your pain:
      ConstantComes and goesIntensity variesIntensity doesn't varySharpShootingTravelsRadiatesAchyThrobbing

      Do you get?
      Pins and needlesTinglingNumbnessNone

      Since the problem started it is:
      About the sameGetting betterGetting worse

      What makes the pain worse?
      SittingStairsBendingStanding up from a chairReaching above headLifting weightProlonged standingReaching behind backWalkingPushing

      How do you feel first thing in the morning?

      Do you have morning stiffness that takes over one hour to settle?
      YesNoSometimes

      Does your pain get better or worse during the day?
      BetterWorse

      Does your pain affect your sleep?
      YesNoSometimes

      Do you have to sleep in a certain position to avoid pain? If yes, what position?
      YesNo

      Out of 10 (with 10 being as bad as it gets, and 0 being none) how much does your pain interfere with:
      Work
      Sports
      Daily Living
      Sleep

      What activities, movements, actions or goals do you want to achieve if you didn’t have this problem? (list at least 3)

      What does your ability to do these activities, movements, action and goals look like right now? (i.e. can’t do at all, able to do but a struggle etc)

      What do you think of the main issues stopping you from achieving these goals right now? (i.e. not flexible, not strong, poor balance, work long hours, etc)

      How important is it for you to get rid of this problem right now?
      Massively importantSomewhat importantNot important at all

      Consenting to treatment

      I consent to treatment from The Physio Therapy Centre and understand the risks of Coronavirus and appreciate that all precautions are in place to minimise this risk. I agree to inform the clinic if my circumstances change in relation to the questions above.
      YesNo

      Digital Signature

      Please use the mouse if on a computer to add your signature or your finger if using a tablet or mobile.