Positive Steps Participant Form
In order to help you achieve the greatest benefit from Positive Steps, we need to know a little more about you. Please take a few minutes to complete this questionnaire. The clinician may discuss the contents with you in more detail if required.
Names *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Email *
Your answer
Telephone Number *
Your answer
Do you currently have any injuries? *
If yes, please provide further details
Your answer
General Health
Do you suffer with any of the following conditions?
Asthma? *
Heart Problems? *
Rheumatoid Arthritis? *
Diabetes? *
Osteoporosis? *
Recent surgery? *
Recent weight loss? *
Bladder and bowel problems? *
Pain during the night? *
Difficulty walking? *
If you answered yes to any of the above, please provide further details.
Your answer
Are you taking any medication? *
If yes, please provide further details.
Your answer
Have you ever suffered with back or neck pain? *
If yes, please provide further details.
Your answer
Do you take part in any regular exercise or hobbies? Please tell us more. *
Your answer
What are you hoping to achieve from coming to Positive Steps?
Your answer
Thank You
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