Address
GP Name & Address:*
CURRENT HEALTH REPORT
Reason for attending physiotherapy treatment Please take time to outline why you have arranged to attend Physio & Wellness Clinic for a physiotherapy assessment. What is your main complaint? When did it start? Please outline any past medical history pertinent to your presenting condition. *You will get more from your consultation if you spend time giving this question some thought and providing specific information*
SLEEP SCREENING
EXERCISE SCREENING
NUTRITION SCREENING
MEDICATION/SUPPLEMENTS
PELVIC FLOOR SCREENING
The following section will ask you questions relating to your bladder, bowel and sexual function. We ask these questions as it is important for us to screen the pelvic floor. The reason for this is that the pelvic floor forms an integral part of your 'core' muscle function. Some bladder and bowel issues can suggest that the pelvic floor is potentially weak, over-active or injured. If this is the case, it can influence back pain/function as well as general hip and lower limb function. If you do NOT feel comfortable answering any of these questions, please simply leave blank:
BLADDER
Thank you for taking the time to complete this form! We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation. We rely on your feedback to help us improve our services. Your input is greatly appreciated.
