Initial Assessment Information

Rushmere Physiotherapy Clinic

Please complete this form prior to your Initial Assessment
Have you booked an appointment?
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 NameLast Name
Email
example@example.com
General area of issue
Side
Side
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?
What would you score your pain most of the time?
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)
Since the onset of your symptoms do you experience any of the following? (tick for yes)
Since the onset of your symptoms do you experience any of the following? (tick for yes)
General Health - (tick for yes and put any notes in the box below)
Notes on General Health
Are there any particular treatments you are interested in?
Any other information you feel we should know
Please email any relevant letters you may have to physio@ipswichphysio.com before your session
Should be Empty:

Rushmere Physiotherapy Clinic