Your Name (required)
Date of birth (required)
Please select all conditions that apply to you
DiabetesAsthmaHeart ConditionHigh Blood PressureOsteoporosis (brittle bones)Weight loss for no obvious reasonCancerEpilepsyAny other breathing difficultyCardiac pacemakerRheumatoid arthritisExcessive sweating at nightPins and needles or numbness
Have you had any of the following problems
DVT (blood clot in your leg)Pulmonary embolus (blood clot in your lung)
Are you or could you be pregnant:
YesNo
Do you Smoke?
Have you had any fractured bones?
If yes, which bones and when?
Have you had any surgery?
If yes, please outline what the surgery was?
Do you have any other health problems or illnesses?
If yes, please outline
Are you using medication to thin your blood?
Have you ever used steroids?
If yes, please outline when and for how long?
Have you had any blood tests, xrays or scans?
If yes, please outline what for and when?
Are you using any other medication?
If yes, please list the names/strength and usage
If you have neck pain, please tick all that apply
HeadachesDizzinessDifficulty SwallowingFainting/BlackoutsNauseaDouble/Blurred VisionProblems with speechRinging in your ears
If you have lower back pain, please tick all that apply
Coughing/Sneezing increases your backpainA change in your bladder or bowel habits since your back pain startedPins and needles or numbness in genital or anal areasTripping or difficulty controlling your legs while walking
1. Mobility
I have no problems with walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about
2. Self-care
I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself
3. Usual activities (including work, exercise, and leisure activities)
I have no problems doing my usual activitiesI have slight problems doing my usual activitiesI have moderate problems doing my usual activitiesI have severe problems doing my usual activitiesI am unable to do my usual activities
4. Pain / Discomfort
I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort
5. Anxiety / Depression
I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed
What do you expect from Physiotherapy?
What do you think is the cause of your problem?
Do you have any worries regarding your problem?
How is the problem affecting your everyday life?
I agree to my anonymised data being used in ongoing clinical audit data (until such time as I notify otherwise). More Information
I have read and agree to the privacy policy.
