Please try your best to answer all relevant questions. Please be reassured that information you give will be completely confidential.

Present complaint:

Duration (e.g.. days, weeks, months, years)

Have you seen a medical professional about this complaint, if so who

Have you had further investigations such as X-ray or MRI, if so when and where were these images taken

Does your pain wake you at night

If you can score your pain out of 1-10, 10 being the worst pain imaginable, what is your pain right now?

Can you describe in words the pain you feel and where?

What activities or movements aggravate your pain?

What movements or positions relives your pain?

What do you hope to achieve with Physiotherapy?

Do you consent to Physiotherapy?