That Farming Physio -New Client Form
This is the intake form where I get all the data type information that makes a difference to how you feel - you have another form for all the legal information too. 

Please know that this is just data - it's information to see what is happening in your life and your body.  I am not here to judge, just to find things that may make your life feel better
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What is your name (first/last)
What would success at the end of your physiotherapy treatment package look like for you? 

Have you any scans/reports etc that you are able to attach to this email regarding this injury? The more information I have the better - scan reports, where they were done if you haven't got them, letters, etc. Please email them to me if you do.
Clear selection
Sleep -
What time do you go to bed at night?
What time do you wake up?
How many times do you wake in a night?
Do you wake up refreshed?
Fuel (no judgement, just asking as it's relevant) and in general is fine
What do you eat for 
*Breakfast?

What do you eat for 
*Lunch

What do you eat for 
*Dinner

What do you eat for 
*Snacks

Hydration
How much water do you drink?

Hydration
How much Coffee? (is this with milk/sugar)
Tea?

Hydration
How much ...
Juice?
Fizzy? (is this full sugar or zero)
Energy drinks (is this full sugar or zero)
How much movement do you get in your day? 
Do you count your steps? If not, how many minutes/hours of walking would you do in a day? Is it on a hill/flat? How many days do you do this?
Do you do any resistance training? (Body weight/gym)
How often do you do it? 
If no, have you previously done it?
What is your job? What does that involve day to day?
How is your general health?
Do you take any medications on a regular basis? Do you take any medications for this issue? If yes, please name medication, and if possible the dose
Please list at least three things you can't do right now because of your injury.
You may think "I can do everything" but think about whether you can do it as normal. 
Have you ever had surgery? If yes, where/when/what for/how are you now? 
Have you ever had any other injuries? Accidents? Fractures? Please write as much detail e.g. injury, date, side, rehab you did, how it is now?
Have you had any accidents/car accidents?  Please write as much detail e.g. injury, date, side, rehab you did, how it is now?
Are you right or left handed or ambidextrous?
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