Name*
Phone Number*
Email Address*
Date Of Birth*
Where is your pain? Please choose one site were your main pain is today. Note : Ticking more than one area is acceptable however non related pathologies may need to be assessed and treated separately.*
Lower BackUpper BackNeckHead / HeadacheFoot / ankleShin kneeThighHipStomachChest (front)Chest ( back)ShoulderUpper armElbowForearmWrist / hand
Out of 10, with 0 being no pain and 10 the most pain you can imagine please rate your pain at the moment.*
When did this pain start?*
How has your pain changed over time?* SameBetter but still soreWorse
Does your pain refer away from the site? Eg lower back referring to the back of the thigh and down the leg*
Do you have pain at night when trying to sleep or wakes you from your sleep?*
What makes your pain worse?*
What (if anything) makes your pain better?*
Have you seen any other person for this issue? (eg your doctor - another physio - chiro - massage therapist - other)*
What medications are you currently taking?*
Have you had any x-rays / scans of this problem?*
Have you had this issue in the past?*
What helped to resolve it then? Or did it resolve at all?*
Have you had any unexplained weight loss prior to this issue?*
Is there anything you wish to add as a comment?*
