Confidential Patient Case History

As a Physiotherapy practice providing comprehensive care, we focus on your ability to be healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly, to treat the cause of your condition (not just treat the symptoms or place a temporary patch over your condition); and thirdly, to offer you the opportunity of improved health potential and wellness services in the future. Answering the following questions will give us a profile of your health.

First Name *

Last Name *

Date of birth? *

Phone Number: *

Email Address *

What is your major problem? *

What do you hope to achieve from your consultation today? *

How long have you had this problem? *

Have you had this or a similar problem in the past? *

What is your average pain?

0 (No Pain)12345678910 (Extreme Pain)

What activities aggravate your condition?

What have you tried to relieve your condition?

What activities are limited as a result of your condition?

What type of work do you do?

Do you do regular exercise? Please describe.

Have you seen any other health Professionals for this problem?

If you have seen another health Professional please list details below:

List any medication you are taking

Have you ever taken oral corisone or prednisone (including asthma medication such as pulmicort, symbicort, flixotide or seretide)?

YESNO

Are you pregnant?

YESNO

Please list previous surgery. (Please include Date and surgery)

Do you have or have you ever had?

High blood pressureHeart attackHeart problemsStrokesDiabetesA pacemakerAn aneurysmCancerOsteoporosisRheumatoid arthritisAnkylosing spondylitisPsoriatic arthritisReiter's arthritisSpinal traumaSpinal fractureSpinal surgeryDislocationsLigament injuriesCartilage injuriesOsteoarthritisDizzinessDVT

Patient's Signature *

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Date: *

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