Pre-Online Consult Questionnaire
This questionnaire will allow us to ensure you are suitable for an online consult, it will also enable us to have a very productive online appointment. Please put as much information as possible for each section and select SUBMIT at the end. A Performance Edge Physio or Receptionist will be in touch after submission to book you in or discuss the next stage.
Which Physio will your online consult be with?
I don't mind / Next available Physio
Who you are
The more we know about you, what you do for a living and what you do for fun/exercise, the more we can help you reach your goals.
Title - Mr/Ms/Mrs/Miss/Dr
So we can call you back to arrange a time
Date of Birth
Date of Birth
Be Specific. Full-time/Part-time/Casual? Do you study? What do you study? Retired?
What sports, exercise activities and/or hobbies are you into? How often do you do these throughout the week?
Play sport? What level? Do you train? What days do you train and compete?
Do you have any specific goals for this consult?
Are there any important events coming up in the near future (2-3 months)
'The diagnosis is in the story'. Please fill in as much of this section as possible as it really does assist us in finding out what is going on so we can make a solid plan.
Is this a new, old or recurring injury?
Please draw on the image where your injury is
When did the pain start or when was the original injury?
X Weeks, X Months, X Years, Not Sure
Have you had this injury before? When?
How long did it take to settle down? Did you receive treatment
How would you best describe your pain?
Hot or burning
Punishing or cruel
Tiring or exhausting
Please indicate on this scale (draw) how good your pain is at best (0 = painfree) AND ALSO at worst (10 = most severe pain you've experienced).
If your pain/injury is related to a joint (knee/hip/shoulder) do you have any of the following symptoms?
Does anything make your pain/injury feel better?
What makes your pain/injury feel worse?
Especially comment on Daily Activities such as cooking, cleaning, dressing, driving, working etc. Does your go away after a while. How long does it take for the pain to start. How long does it take for the pain to settle aftewards.
Does your pain have a pattern over the day/night?
Is it worse in the morning, the evening, does it wake you up at night?
Do you have Pins and Needles?
Type a question
Have you had any diagnostic imaging for this injury
Yes (upload any reports below)
Do you have any previous reports or diagnostic imaging for this injury? Upload them here
Upload any documents, reports or imaging reports related to your injury.
Your Medical History
Some medical conditions can have a big impact on your pain and recovery. Please provide as much detail as possible to make sure we don't miss anything important.
Please tick if you have or have had any of the following
Unexplained weight loss/gain
Smoking (comment in 'other' your smoking history)
Please list any surgeries you've had in the past 5 years
Have you experienced any of the following since the injury?
Bowel or Bladder Incontinence
Bowel or Bladder Retention
Are you currently taking any medication?
How did you find out about our Telehealth Service?
Search Engine (eg: Google)
Social Media (Facebook, Instagram etc.)
Please scribble your signature here
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