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.
Your Name (required)
Your Email (required)
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
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
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
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
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
I consent to treatment from Chichester Physio Ltd 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
Please use the mouse if on a computer to add your signature or your finger if using a tablet or mobile.
