Personal Details
Full name *
Your answer
Address *
Your answer
Date of Birth *
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Mobile Number *
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Email *
Your answer
Who referred you? *
Details of Referrer *
Please provide details of who referred you to the clinic
Your answer
Who is your GP/Specialist *
Your answer
Area of Injury OR goal with Pilates/Yoga classes *
Your answer
Occupation and Employer
Your answer
Briefly describe your current problem? (E.g. Lower back pain, sprained ankle)
Your answer
How long have you had the symptoms?
Your answer
Briefly explain how your symptoms started?
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Have you had this problem before?
If Yes: Please provide information of any previous related treatments you had
Your answer
Is your problem getting
Please give details of any investigations you have had for this complaint. (E.g. Xray)
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Are you currently on any medication and if so for what condition/purpose?
Your answer
Please tick any of the following conditions you may have
Please include details of any of the above boxes ticked or other health issues not mentioned
Your answer
What exercise do you currently participate in?
Your answer
If attending for a class - what type of classes have you done before
Your answer
Are you pregnant or have you recently given birth in the last 6 months? If so please give details - the pregnancy, mode of delivery, postpartum history, number and age of children, bladder or bowel (stress incontinence) issues etc
Your answer
Have you ever been advised not to exercise by your doctor and if so why? *
Your answer
Please list an activity you are finding difficult (1 of 3) *
Your answer
Please score the activity #1 at present *
Unable to perform activity
Able to perform the activity at the same level as before the issue
Please list an activity you are finding difficult (2 of 3) *
Your answer
Please score the activity #2 at present *
Unable to perform activity
Able to perform the activity at the same level as before the issue
Please list an activity you are finding difficult (3 of 3) *
Your answer
Please score the activity #3 at present *
Unable to perform activity
Able to perform the activity at the same level as before the issue
INFORMED CONSENT --------------------------------PLEASE ENTER YOUR INITIALS TO ACCEPT THE FOLLOWING - I accept responsibility: to pay the fees charged by the practice for treatment of fees incurred for late cancellations (less than 3 hours notice incur €20 fee), and failure to attend appointments (missed appointments incur the full fee) for all fees for treatment in the event that liability for fees are not accepted by the insurance company nominated above.I have read and understood the above statements relating to consent for treatment. I understand that I may be contacted via sms and email in relation to my appointments and offers. I offer my consent to receive treatment within the practice and agree to this consent remaining valid until such time as I withdraw my consent. I also give consent to hold my personal information online on a secure server using my electronic notes system. (Please note we will never use or sell your personal information) *
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Your answer
Please enter the time and date of consent *
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