PhysioTherapy Screening Form – NeuroMuscular Physical Therapist

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

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Date:

* Name / Surname

First

Last

* Address:

Street Address

Address Line 2

City

State / Region / Province

ZIP / Postal Code

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

If yes, when is a better time to call you?

Morning

Afternoon

Evening

Section 5

FOR INJURED CLIENTS.

It has been present since?

If other please explain

What makes your discomfort better (relieving factors)

What makes your discomfort worse (aggravating factors)

Please summarise any previous treatments and outcomes

Section 6

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What were the results?

If Yes, please give brief details.

Section 7

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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

If YES, How many a day?

Section 8

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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

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* 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.