Radial Shockwave Therapy Pre-Treatment Questionnaire
Please fill out your personal details and medical history for assessment.
Patient Details
Date
*
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Date of Birth
*
/
Day
/
Month
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Condition Information
Area being treated
*
Heel / Plantar fascia
Achilles tendon
Elbow
Shoulder
Knee
Hip / Glute
Other (specify)
Do you have any imaging for this condition?
*
Yes
No
How were you diagnosed with this condition?
*
Duration of pain
*
Less than 6 weeks
6 weeks – 3 months
3 – 6 months
More than 6 months
Pain rating (0–10)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Activities that aggravate pain
Previous treatments tried
Rest
Physiotherapy / Exercise therapy
Orthotics
Medication
Cortisone injection
Previous shockwave therapy
Other (specify)
Medical Screening
Are you currently pregnant?
*
Yes
No
Do you have a bleeding disorder?
*
Yes
No
Are you taking blood thinning medication?
*
Yes
No
Have you had a corticosteroid injection in this area within the past 6 weeks?
*
Yes
No
Do you have an infection, open wound, or skin condition in the treatment area?
*
Yes
No
Have you been diagnosed with a tumour or cancer in the treatment area?
*
Yes
No
Do you have any nerve or circulation problems affecting this area?
*
Yes
No
If you answered YES to any of the above medical screening questions, please provide details
Additional Information
Are you currently receiving treatment from another practitioner for this condition?
Yes
No
If yes, please provide details of other treatment or practitioner
Any other information the practitioner should know
Submit
Should be Empty: