Health Questionnaire

We believe that everyone regardless of age, diagnosis, or injury, has the potential to improve their health and well-being. Through accurate assessment, diagnosis, and correction of postural and habitual faults, people can build towards a stronger and healthier future.

COMPLETE THE FORM

To protect you from injury,
please fill in the following form

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 "Submit" once you have completed the form.

Name *

First

Last

Phone

Email *

EXERCISE

How often do you exercise?

Never
Less than once a week
2-4 times / week
More than 4 times / week

What type of exercise do you do?

Walking
Running/Jogging
Gym
Pilates/Yoga
Sports
Other. Please list

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

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

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Have you had a stroke? If yes, details?

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Do you have heart problems? If yes, details?

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

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Do you have Diabetes? If yes, details?

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Do you suffer from epilepsy? If yes, details?

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

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

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

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GENERAL HEALTH

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

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

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

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

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

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

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

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

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

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Do you experience chest pain? If yes, details?

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

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

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Do you experience difficulty breathing? If yes, details?

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

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

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

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

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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?

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:

Constant
Comes and goes
Intensity varies
Intensity doesn't vary
Sharp
Shooting
Travels
Radiates
Achy
Throbbing

Do you get?

Pins and needles
Tingling
Numbness
None

Since the problem started it is:

About the same
Getting better
Getting worse

What makes the pain worse?

Sitting
Stairs
Bending
Standing up from a chair
Reaching above head
Lifting weight
Prolonged standing
Reaching behind back
Walking
Pushing

How do you feel first thing in the morning?

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

Yes
No
Sometimes

Does your pain get better or worse during the day?

Better
Worse

Does your pain affect your sleep?

Yes
No
Sometimes

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

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

Work

Selected Value: 0

Sports

Selected Value: 0

Daily Living

Selected Value: 0

Sleep

Selected Value: 0

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 important
Somewhat important
Not important at all

Consenting to Treatment

I consent to treatment from Core Physio 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.

Digital Signature *

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

Health Questionnaire

To protect you from injury,please fill in the following form

PART 1: CONFIDENTIAL MEDICAL QUESTIONNAIRE

EXERCISE

GENERAL HEALTH

PART 2: CONFIDENTIAL PATIENT CASE HISTORY

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

Consenting to Treatment

To protect you from injury,
please fill in the following form