New patient questionnaire | Prepare To Perform

First name

Last name

Birthday

Day

Month

Year

Email

Phone

Profession

Multi-line address

Country/Region

Address

City

Zip / Postal code

General Practitioner Details (in case of emergency)

Contact name and number of second person in case of emergency

Do you have a current injury? If yes, describe.

Have you suffered concussion/s?

Yes

No

If yes, how many and when was the most recent?

Please provide a summary of previous injuries or surgery.

Are you aware of any physical reason why you should not receive treatment? If yes, provide details.

Occupation

Height (if known)

Weight (if known)

How much water do you usually drink in a day (approximately)?

How many times have you fallen in the past 12 months?

If you have fallen in the past 12 months, did it result in injury?

Yes

No

I don't know

During the past month have you been feeling down, depressed, or hopeless or bothered by having little interest or pleasure in doing things?

Yes

No

Please list any known allergies (including medications, latex, etc.) below

Current Condition

When did this problem(s) first begin/date of onset? If chronic, when did you seek medical treatment?

Is your current condition related to recent surgery?

Yes

No

If yes, specify date of surgery.

Describe the problem

Explain how the problem occurred

Have you had this problem before?

Yes

No

If yes, how many times?

How are you taking care of the problem now?

Is your problem.....

Staying the same?

Getting better?

Getting worse?

Other

Do you have any numbness, tingling, or burning?

Yes

No

If yes, constantly or intermittently?

Constant

Intermittent

What functions could you perform before, that you now are unable to do?

Please explain any specific treatment you have received for this problem, such as previous physical or occupational therapy, chiropractic visits, pain medications, etc.

Have you received X-rays, MRI, CT scan, ultrasound or bone scan for this problem? If so, please list the dates and results (if known)

Please list current medications if you're taking any (including prescription, over the counter, and herbal). You can also provide our staff a list to copy.

Social History and Wellness Questions

Do you use tobacco or e-cigarettes?

Yes

No

Please list current medications (including prescription, over the counter, and herbal). You can also provide our office staff a list to copy.

Yes

No

Do you drink alcohol?

Yes

No

How often have you completed at least 20 minutes of exercise, such as jogging, cycling, or brisk walking, prior to the onset of your condition?

At least 3 times per week

1 to 2 times per week

Rarely or never

I will advise the therapist if there is any change in my physical condition which will alter my response to any of the questions on this form.

By submitting this form, you acknowledge that your personal information will be collected and handled in accordance with our Privacy Policy.

Thanks for booking an appointment. Please complete this new patient questionnaire to provide an important record that will inform your physiotherapist and save some time in the consultation.