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Holistic Therapies Screening
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GP Name & Address:*
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?
Medical Questionnaire
Are you currently experiencing OR ever been diagnosed with any of the following conditions?
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?
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Yes
No
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Have you ever had an episode of Lower back pain?
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Yes
No
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Have you had any recent injuries or surgery?
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Yes
No
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Which, if any, of the following conditions have you been diagnosed with or had treatment for
Asthma
Arthritis
Stroke
Cancer
Bronchitis
Depression
Diabetes (Type 1)
Diabetes (Type 2)
Dermatitis or other skin conditions
Other
NONE OF THE ABOVE
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