Women's Helath Coaching Intake Form

Women's Health Coaching Intake Form

Address

GP Name & Address:*

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

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

Is your condition interfering with your: Required

Work

Sleep

Daily Routine

Other (explain)

What are your most bothersome symptoms currently?

Whe did this health issue begin?

When did you last feel healthy?

What have you tried to improve your health / relieve your symptoms?

What (if anything) has been helpful?

What (if anything) has not been helpful?

List any foreseeable barrier that may prevent you from committing the next 4-6 months to improving your health.

How will you define success at the end of our work together? If you could wave a magic wand, what would you like to have happen in your health and life?

Is there anything else I should know?

What are your top 3 questions for me?

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.

info@physiowellnesshub.ie

+353-851-372002

Women's Health Coaching Intake Form

Address

GP Name & Address:*

CURRENT HEALTH REPORT

Location

Opening hours