Personal Details
Full name *
Your answer
Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Mobile Number *
Your answer
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?
Your answer
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)
Your answer
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. I accept responsibility 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 of that session). This is at the discretion of the clinic. I also accept responsibility for all fees for treatment in the event that liability for fees are not accepted by the insurance company nominated. As per the new GDPR guidelines set out by the European Parliament on 25th May, I give consent to BodyBalance Physiotherapy for using my personal data so that I may be contacted via SMS and email in relation to my appointments, my home exercise programme, my invoices and receipts and our monthly newsletter. I also give consent to hold my personal information online on a secure server using the electronic notes system, (please note we will never use or sell your personal information). If required, I give permission to the therapist to contact my GP or relevant Consultant about my pathology. In the future, if I wish to withdraw my consent, I agree to contact BodyBalance Physiotherapy in relation to this. I have read and understood the above statements relating to consent. *
Please enter your initial
Your answer
Please enter the time and date of consent *
MM
/
DD
/
YYYY
Time
:
Submit
Never submit passwords through Google Forms.
This form was created inside of bodybalance physiotherapy. Report Abuse - Terms of Service - Additional Terms