Intake Form -Kabworld Physiotherapy Services
Please complete this intake for new patients prior to your visit. We will not be able to start your visit unless this form is completed
Have you been diagnosed before
Kindly list all medications you are currently on
Intermitent fever in the last 3 months
Bower or Bladder issues in the last 3months
Road traffic accident or were admitted in Emergency room in the last 3months
Fracture or been placed on any special medication in the last 3months
On a scale of 0-10 what value can you rate the severity of your condition
No problem at all
So worst that you could not do anything
Are you a New patient or Existing patient?
Injury description (brief summary)
If Yes, what is the diagnosis?
How has your activities of daily living been affected?
Please click to read or download our "consent to treat" policy and thereafter click an answer below if you agree or disagree to the policy written here:
I have read the above name consent to treat form and here say:
a copy of your responses will be emailed to the address you provided
A copy of your responses will be emailed to the address you provided.
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