Surname
*
First Name
*
Date of Birth
*
Email Address
*
Reason for consultation
*
Side of problem
*
Left
Right
Both
Date of injury / Onset of symptoms
*
Prior Treatment
Physiotherapy
Podiatry
Surgery
Other
Date of surgery
*
Type of surgery
*
Please list any other medical conditions
Please list current medications
*
Please list any allergies
*
What is your current smoking status?
*
Never smoker
Ex-smoker
Current smoker
When did you quit?
*
How many cigarettes?
*
Please list your normal exercise activities/sports
Occupation
*
Current height (cm or m)
*
Current weight (kg)
*
Heart disease
*
Yes
No
I am receiving treatment for it
The problem limits my activities
High Blood Pressure
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Lung Disease
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Diabetes
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Ulcer or Stomach Disease
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Kidney Disease
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Liver Disease
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Anaemia or Blood Disease
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Cancer
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Anxiety / Depression
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Osteoarthritis / Degenerative Arhtritis
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Back Pain
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Rheumatoid Arthritis
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Blood Clots
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Other Medical Conditions
*
Yes
No
I am receiving treatment for it
The problem limits my activities
Date
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