Clinic Questionnaire

The initial intake form is important because many health problems can mimic disorders of the musculoskeletal system. This establishes your health background, for things such as surgeries, accidents, the onset of your immediate condition, and other details affecting current health. Examining your history also helps the physiotherapist determine whether the immediate reasons for your consult is, in fact, musculoskeletal-related.

Please fill out all information to the best of your ability and note patients who have reservations about ticking any questions may discuss these with the physiotherapist personally. 

All case histories are treated with absolute confidentiality.

Name *
Name
Address *
Address
If you do not have a regular GP - Who did you see last. If you don't have one - tick "I don't have one"
We need to know this as some health funds require specific item numbers
Are you covered for physiotherapy?
Is this related to either:
We are grateful that our practice grows by referral
Have you ever seen a physiotherapist before?
Major Complaint
include symptoms such as type/location/radiation/duration
include information such as history/causation
Was there any of the following prior to or during the onset?
Please tick
Please specify if you ticked 'Other significant event'
Is the problem getting worse?
Comment:
Are your symptoms worse at night or any specific time of the day?
If yes, comment:
Does your current problem involve any of the following?
Please specify if you ticked any of the above boxes
Have you had any other treatment for your current problem?
Medical History & General Health
Please mark Yes or No, and COMMENT where applicable
Do you exercise regularly?
Comment:
Have you had any form of surgery?
Are you currently taking any form of medication?
including any over-the-counter medicine
Are you currently taking any form of vitamins or supplements?
Do you have, or have you ever had, a serious health problem such as hypertension, heart disease, diabetes or any form of cancer?
Have you had any broken bones, sports injuries, bad falls, accidents or dislocations?
If yes, please specify
Have any of your family members suffered from any serious or hereditary diseases? (e.g. cancer, diabetes, heart disease or any other major health problem)
Do you have poor sleep?
Comment:
Do you suffer from fatigue?
Comment:
Did you / Do you have occupational stress?
Comment:
Do you get pain in any of your joints?
Comment:
If yes, is it worse in the night?
Comment:
Are you often troubled by headaches?
Comment:
Has your weight changed more than 4 kg in the last year?
Comment:
Have you had any changes in your bowel or bladder pattern?
Comment:
Does stress seem to make your main problem worse?
Comment:
Are you subject to blackout, dizzy spells, or faints?
Comment:
Do you have poor balance?
Comment:
MEDICAL CORRESPONDENCE AND REFERRAL
Do you give consent for your clinical information to be communicated to your general practitioner or preferred health practitioner? *
Our practice specialises in treating problems of the spine and associated disorders of the nervous system. A proportion of our patients come via referral from their medical practitioner. As such, it is standard practice to correspond with your medical practitioner where appropriate.
If under 18, full name of parent or legal guardian
If under 18, full name of parent or legal guardian
home, work or mobile number

Location

17 Wittenoom Street,
East Perth WA 6004

☎︎ 08 9221 8458

info@spinesportscentre.com.au