Initial Assessment Form [802066]

Initial Assessment Form
Full Name

First NameLast Name
MaleFemale
E-mail
Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry
Date of Birth

MMDDYYYY
1) Where is the problem area? (please mark the pain/problem on the body chart below in black)

Also identify on the body chart if you have any pins and needles/tingling, burning or numb sensations anywhere (in red, using the colour option tab on the top left) anywhere since the onset of your problem.
2) What is the nature of the problem? (please use the options listed by ticking the appropriate boxes – you may tick more than one, or describe your symptoms in the box below)
SharpAchingNaggingStabbingShootingBurningDeepSuperficial (near the surface)Constant (never goes away)Intermittent/near constantIntermittent/infrequentOccasional
Your symptoms
3) What score, or range, out of 10, what would you give your pain/problem? (0 is nothing/like normal, and 10 is the worst ever imaginable)
(From 0-10)
4) When / how did it start? (Please include how long you have had the problem for, if it was a sudden or gradual onset, and if it has changed since you first noticed it and in what way)
5) What activities or movements make it worse?
6) What, if anything, makes it feel better?
7) How does the pain vary during the day? (Do you wake up with pain or stiffness? How long does it last? Does it get better or worse as the day goes on? Is it only there during/after the aggravating activities?)
YesNo
If you answered 'Yes', please describe how in the box below (Does it wake you at night? Does it hurt when you turn over?)
YesNo
YesNo
If you answered 'Yes', please state which treatment / intervention you had and whether it helped, in the box below.
NoXRayUltrasound ScanHad investigationMRI/CT ScanBlood testsReferred forOther
12) What, if anything, was found from the investigation(s)?
13) Have your toilet habits or behaviours changed since the onset of your problem?
14) What is your occupation? Is your work affected by this problem?
15) What hobbies do you have? Are they affected by this problem?
Relevant Medical History
Heart conditionsLung/breathing problems, e.g. AsthmaDiabetesEpilepsyMajor SurgeryRheumatoid Arthritis (either yourself or a family member)FracturesCancer (past or current)Thyroid problemsNone of the above
If you ticked any of the above, or have a condition not listed, please give details below (E.g. Type 2 Diabetes; broken femur/thigh bone September 2013)
Bladder/bowel problemsNumbness/sensation changes in the saddle areaNausea/vomitingHeadaches (abnormal for you)Blurred or double vision (abnormal for you)Dizziness (abnormal for you)Pain when you cough, sneeze or laughSudden/unexplained weight lossFainting/blackouts/drop attacksProblems with speech or swallowingNight sweatsUnremitting night painLoss of appetiteMalaise - feeling generally unwellNone of the above
If you ticked any of the above, please give details below (E.g. headaches at the back of my head when the pain gets worse; loss of control of my bowel movements; unable to empty my bladder)
18) Have you had steroid treatment for anything?
Yes, currentlyYes, previouslyNo
If you answered yes, please give details where possible, e.g. which steroid, for what condition you had it, and when you had it.
19) Are you currently taking anticoagulant (blood-thinning) medication?
YesNo
20) Please list any medication you are on currently
21) And lastly, what do you hope to gain from physiotherapy?
Please select your preferred means of treatment:
If you chose the GOLD option (the online consultation), how would you like to be contacted to arrange an appointment?
I confirm that all the information I have given is correct.I confirm that I am 18 years old or over.I confirm that I am ordinarily resident in the UK, the Channel Islands, Northern Ireland, the Republic of Ireland, or the Isle of Man.I confirm that I am a foreign national, but that I am currently staying in the UK, the Channel Islands, Northern Ireland, the Republic of Ireland, or the Isle of Man, and that should this change whilst I am using Physio Clinic Online's services, I will notify Physio Clinic Online immediately.I confirm that I am ordinarily resident in the UK, the Channel Islands, Northern Ireland, the Republic of Ireland, or the Isle of Man but that I am currently abroad/on holiday in a country other than the USA, Canada or Australia.I have read, understood and agree with the terms and conditions.
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Initial Assessment Form

Relevant Medical History