Pre-consultation form – Castlemaine Physiotherapy

Address
Occupation
Sports/Activities/Hobbies
Height
Weight
Main Problem – Location
Please describe the area of pain
Mechanism
Was there an obvious cause, ie. fall/accident
Duration
How long have you had symptoms for?
Type of pain
Please describe your type of pain, ie. is it constant or does it come and go, ache/burning/pinching pain, pins and needles, clicks/clunks etc.

On a scale of 0-10 where 0 is no pain, and 10 is the worst pain you have ever had…
Intensity – at its best
Intensity – at its worst
Aggravation
What activities, positions etc make your pain worse?
Ease
What activities, positions etc ease your pain?
Other
Is there any other relevant information you’d like to tell us?
24 hour behaviour
Does your pain change noticeably from morning to afternoon or at night?

Previous History
Have you had this issue before? If yes please describe.
Previous Treatment
Have you had any previous treatment for this issue?
Investigations
Have you had any investigations for your pain? Such as x-rays, MRIs etc. If yes, please describe.

General Health
How would you describe your current general health?
Medical conditions
Do you have any other current, or ongoing medical conditions?
Weight Loss
Any unexplained recent weight loss?
Medications
Please list your current medications.
New medications
Have there been any changes to your medications, prescribed or otherwise, since the onset of this issue?
Lifestyle Factors – Work/Activity/Hobbies
Has this issue stopped or changed the way you complete any of your regular activities? If yes, please describe.
Any other relevant information
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