PhysioTherapy Screening Form Neuromuscular Physical Therapy Screening Form There are 2 parts to our consultation screenings. Firstly please complete and submit this form at least 24 hours before you first appointment. By doing so we can spend more time treating you during your initial appointment. We will bring a copy of your submitted form to the first appointment for you to sign. The form will take approximately 10 minutes to complete. Once you have completed the form click submit at the bottom of the page and most importantly check the following page states submission has been successful. Secondly– and ideally- we would like to speak to you over the phone for a few minutes to further understand whats happening. Once we have your details we will attempt to make contact by phone to briefly discuss the details in your submission. We like to do this in order to utilise time. If you unable to speak prior to the appointment please indicate on the form. We would ask you to do the following before your appointment. 1. Make sure you complete and submit your screening form. 2. Wear appropriate clothing for the appointment- shorts, t-shirt, sports top/bra- depending on the areas you wish to be treated. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18. Section 1 .............................................................................. Date: * Name / Surname First Last * Address: Street Address Address Line 2 City State / Region / Province ZIP / Postal Code Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao, People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe Country * Email Home Phone Number * Mobile Phone Number * Date Of Birth Occupation: How did you hear about us? Contact name and number in case of emergency. * We like to conduct a verbal consultation over the phone once your form has been submitted so we can clarify details of your condition prior to treatment. We understand this isn't always possible so feel free to opt out below. Indicate below if you are happy to have a verbal consultation over the phone? Yes No If yes, when is a better time to call you? Morning Afternoon Evening Section 2 .............................................................. * In a few words, whats happened and what hurts? Current medical history. Do you suffer from or have you been diagnosed with any of the following. If Yes, please give details below. I am taking any regular medications I have Diabetes Type 1. I have Diabetes Type 2. I have High blood pressure I have Cardiac/Heart problems. I have Epilepsy. I have Asthma or other breathing problems. I have been diagnosed with Osteoporosis I have joint replacements I suffer from Digestive complaints I have noticed bowel or bladder dysfunction. I have noticed unexplained weight loss. I have been diagnosed with a form of cancer. Section 3 .............................................................. Are you pregnant? Please Select Yes No If yes, due date will be Have you had any previous pregnancies? If so please list years Previous delivery methods- please tick natural cesarean assisted forceps episiotomy Were there any complications? Your menstrual cycle regular irregular PMT Amenorrhoea Endometriosis Additional pregnancy information Section 4 ............................................................... Past medical and injury history. Tick where applicable. We will ask you to provide brief explanations below. I am injured I have been cleared by my doctor to exercise I have been involved in a major accident- such as motor vehicle I have had major surgery I have had bone or stress fractures I have had ankle/foot problems or injuries I have had knee or hip problems or injuries I have had shoulder/elbow/ wrist problems or injuries I have had muscle/tendon/ligament problems or injuries I have had neck problems such as Whiplash I have had lower back problems I am currently off work due to pain or disability I have been diagnosed with hypermobility If you have answered to any of the above, please give brief details here. Is there any other longstanding medical condition or disability not covered above that your therapist should be aware of? (e.g. Parkinsons, MS, ME)? Section 5 FOR INJURED CLIENTS. Your symptom specific history- FOR INJURED CLIENTS. Firstly, are you experiencing pain or discomfort? Select... Yes No If so, is it Select Constant Intermitent It has been present since? On a scale of 0 to 10- 0 being 'no pain' & 10 being extremely painful, indicate your TYPICAL or AVERAGE pain severity. 1 2 3 4 5 6 7 8 9 10 What is your pain right now? On a scale of 0 to 10- 0 being 'no pain' & 10 being extremely painful, indicate your TYPICAL or AVERAGE pain severity. 1 2 3 4 5 6 7 8 9 10 Are you taking any pain relieving medication right now? select yes no Type of medication? Select Painkillers Anti-Inflammatory Other If other please explain How often are you taking them? Select As required Daily Regularly Is the medication helping? Select Yes No Overall is your pain Select Improving Unchanging Worsening Is it worse in Select Morning Afternoon At night There is no pattern of discomfort What makes your discomfort better (relieving factors) What makes your discomfort worse (aggravating factors) Please summarise any previous treatments and outcomes Section 6 ........................................................ Additional relevant information. Firstly, have you had any recent investigations? (X-ray/MRI-scans or blood tests)? Select NO MRI Scan X-Ray Blood Test What were the results? Do you have relevant reports or referrals to provide us with in relation to your treatment. Select Yes No If Yes, please give brief details. * Is there a history of ill health (heart disease, cancer, diabetes) in your family?* Select Yes No If Yes, please give brief details. Section 7 ............................................................... * Do you feel your diet provides you with adequate nutrition?* Select Yes No Please enter your level of stress at home. 0= no stress. 10= extremely stressed Please enter your level of stress at work. 0= no stress. 10= extremely stressed Do you smoke? Select Yes No If YES, How many a day? Do you drink tea or coffee? Select Yes No Section 8 .......................................................... If we are visiting you please indicate opportunites for parking We have a drive you can park on There is a car park you can use There is on the road parking available at no cost There is on the road parking available but there is a charge There is no parking available Section 9. Please add your name to the box. We will bring a copy for you to sign ........................................................... * Name As the person named above, I understand that the therapy service and subsequent treatment programme we devise is based upon our sound skills and practice and the information you have provided about yourself when filling out this medical screening questionnaire. You must therefore inform us about any change to your medical condition as soon as you become aware of it. I accept the above terms and conditions and agree to abide by them. * Signed (please enter name in capitals) We will bring a copy for you to sign on the first visit.