Form-Holistic Therapies Screening

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Holistic Therapies Screening

Please outline GP details and note whether they, or another health care practitioner, recommended that you attend Physio&Wellness Clinic.

Where did you hear about Physio&Wellness Hub?

Are you currently experiencing OR ever been diagnosed with any of the following conditions? * Required

Lower back pain

Pelvic pain

Any other spinal condition

Any other oprthopaedic conditions

High or low blood pressure

Epilepsy (Grand mal seizures)

Heart problems

Osteoporosis/Osteopenia

NONE OF THE ABOVE

Are you pregnant?

Have you ever had an episode of Lower back pain?

Have you had any recent injuries or surgery?

Which, if any, of the following conditions have you been diagnosed with or had treatment for * Required

Asthma

Arthritis

Stroke

Cancer

Bronchitis

Depression

Diabetes (Type 1)

Diabetes (Type 2)

Dermatitis or other skin conditions

Other

NONE OF THE ABOVE

Thanks for submitting!

Physio & Wellness Hub

Unit 2
Carlisle House, Adelaide Road, Bray, Co. Wicklow, A98 K2Y3

Mon & Thu: 9am - 9pm

Tue & Wed: 9am - 3pm

Sat: 9am - 3.30pm

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