PHYSIOTHERAPY NEW PATIENT FORM

Please answer all the below question

How did you learn about our centre? Please specify:

Doctor

Patient

Referral Dr.

Websites

Facebook/Twitter

Magazine

Word of Mouth

Other

1. Which of the following is your reason for consultation? α= Primary ●= Secondary

Low back Pain/ Stiffness

Neck Pain/ Stiffness

Mid-back Pain/ Stiffness

Headache

Numbness/Tingling

Check up

Shoulder Pain

Elbow Pain

Wrist/Hand Pain

Pelvis/Hip/Groin Pain

Knee Pain

Ankle/Foot Pain

General Arm Pain

General Leg Pain

Dizziness

Sport Performance

Pregnancy

Other

Please draw in the area where your symptoms are:

X = pain

O = numbness/tingling

2. How long have you been experiencing your symptoms?

3. How often do you experience your symptoms?

4. On a scale of 1 (mild) to 10 (severe), how bad are your symptoms?

5. What makes your symptoms better?

worse?

6. Have you had these symptoms? If so, when?

7. Any other health changes in the 3 months?

8. Have you seen any doctor about your complaint?

Yes

Who Treatment

9. Are you currently seeing another doctor for other reasons?

Yes

10. Current Medication/ Supplements

Allergic to any Medication

11. Which of the following diseases affect your immediate family?

High Blood Pressure

Thyroid Problems

Arthritis

Joint Problems

Cancer

Heart Disease

Spinal Problems

Scoliosis

Diabetes

Lung Disease

Nerve Problems

Bone Problems

Other, relevant:

12. List Previous
a) Fractures/ Dislocation/ Injuries

b) Illnesses

c) Operations/ Hospitalizations

d) X- ray and When

13. Social History:

a) Do you smoke?

Yes

b) Do you exercise?

Yes

c) Daily Fluid:

Water

Coffee/ Tea

Alcohol/ Cold Drinks

I certify that it is my responsibility to pay all required fees for the procedures or treatments provided to me by the Dr. or Specialist.