Telehealth Consultation Form
This questionnaire will allow us to ensure you are suitable for Telehealth, 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 Receptionist will be in touch after submission to book you in or discuss the next stage.
Which Physio will your consultation be with?
I don't mind, whoever is next available
Title - Mr/Ms/Mrs/Miss/Dr
Date of Birth
Do you exercise?
What type? How often?
Do you have any specific goals for this consult?
Are there any important events coming up in the near future (2-3 months)
Please tick if you have or have had any of the following
Unexplained weight loss/gain
Smoking (comment in 'other' your smoking history)
Has any abnormal bladder/bowel incontinence/retention occurred since this injury started?
Have you had any surgeries in the past 5 years?
Is this a new, old or recurring injury?
Please draw on the image where your injury is
When did your injury occur?
X Weeks, X Months, X Years, Not Sure
How did your injury happen?
Any pins & needles / numbness?
Have you had any past conditions relating to this area?
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.
What aggravates your pain?
What eases your pain?
AM - How does it feel when you wake up?
DAY - How does it feel?
PM - Does it prevent you from sleeping?
PM - Does it wake you in the night?
How did you find out about our Telehealth Service?
Search Engine (eg: Google)
Social Media (Facebook, Instagram etc.)
Please sign below
Should be Empty: