Rushmere Physiotherapy Clinic
Please complete this form prior to your Initial Assessment
Have you booked an appointment?
Yes
No
You will receive a separate email requesting you to complete a different form
Only continue to complete this form if you have not received the form and your appointment is less than 24hours away
Name
First Name
Last Name
Email
example@example.com
General area of issue
Neck
Back
Shoulder
Elbow / Arm
Hip
Knee / Leg
Foot / Ankle
Side
Left
Right
Both
Central
Side
Left
Right
Both
Where is your symptoms? - be as specific as you can
How did it start?
Please describe your symptoms: (Sharp/Dull, deep/surface)
How often are the symptoms there? (Constantly, intermittently, occasionally)
What would you score your pain at its worst?
0 - No Pain
1
2
3
4
5
6
7
8
9
10 - Worst Possible Pain
What would you score your pain most of the time?
0 - No Pain
1
2
3
4
5
6
7
8
9
10 - Worst Possible Pain
What makes the symptoms worse?
What makes the symptoms easier?
Are symptoms worse at any point during the day?
Do you take any medication? (Please state)
Since the onset of your symptoms does your Knee: (tick for yes)
Click
Swell-up
Lock
Give-way or feel like it will
No
Since the onset of your symptoms do you experience any of the following? (tick for yes)
Numbness or pins and needles in your legs
Weakness in your foot (unusually tripping over)
Numbness between your legs (saddle)
Change in your bladder or bowel control
No
Since the onset of your symptoms do you experience any of the following? (tick for yes)
Dizziness
Double or Blurred vision (diplopia)
Difficulty swallowing (dysphagia)
Difficuly talking (dysarthria)
Sudden falls (drop-attacks)
Feel sick (nausea)
Changes in your eye movements (nystagmus)
Numbess
No
General Health - (tick for yes and put any notes in the box below)
Have you had any recent unexplained weight loss?
Do you have Diabetes?
Do you have Rheumatoid Arthritis?
Do you have osteoporosis (thinning of the bones)?
Do you have any heart or lung problems?
Do you have epilepsy?
Have you had Cancer or treatment for Cancer?
Have you taken any steroids?
Do you take anything to thin your blood?
Have you had any X-Rays or Scans for your problem area?
Have you had any recent surgery? in the last 3 months?
Do you suffer a constant and unchanging pain?
Do you smoke?
Notes on General Health
Are there any particular treatments you are interested in?
Acupuncture
Shockwave
Ultrasound
Interferential
Manipulation
Any other information you feel we should know
Please email any relevant letters you may have to physio@ipswichphysio.com before your session
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