New Patient Pre Assessment Form

Section 1 - Personal Details

Name *

First

Last

Email *

Address

Address Line 1

City

State / Province / Region

Date of Birth

Phone

Occupation

Have you had physio treatment before?

Yes
No

How did you hear about the clinic?

Section 2 - Current Problem And Ideal Outcome

The more detail you give, the more it help us to help you.

What is the important thing you want from you upcoming appointment with us? *

How did the injury happen or when did you first start to notice the pain? *

How is your pain / problem affecting you in everyday life? ......( what tasks, movements or activities make the pain is worse?) *

On a scale of 1 - 10 how important is it for you to get a solution to your pain/ problem?

1 = Not very important 10 = Very important

Please list any previous injuries or pains to the best of your memory in chronological order ......even if you think they may be unrelated or happened a long time ago. *

Your Ideal Outcome - Can you tell us what would you be the best possible outcome from coming to see us? *

Section 3 - Medical History

Do you have any medical conditions? Please specify

Are you taking any medication? Please specify

Covid 19 - Have you been experiencing any coughing, illness, or flu like symptoms over the past 7 days

Section 4 - Consent

Please write your name below to consent to treatment at Midlands Physio Clinic *

Are you happy to receive your exercise videos and helpful tips and advice through email?

Yes
No

New Patient Pre Assessment Form

Please out the form below before your initial assessment

Section 1 - Personal Details

Section 2 - Current Problem And Ideal Outcome

Section 3 - Medical History

Section 4 - Consent