North East Physiotherapy Spinal and Sports Injury Clinic Pre Assessment Form

Pre assessment consultation

This entitles you to a pre-assessment consultation to determine if physiotherapy is the right course of action for you.

The physio will organise to call you back and discuss your problem so you are back on right road as soon as possible.

Name

Date of Birth

Occupation

Hobbies

Please indicate location of pain on the body chart to the right

What caused the injury pain and when?

Any previous history of this same problem?

If yes - please give details including treatment received

Any problems with your General Health?

Are you taking any Medication?

What do you think is causing your pain and how is this impacting on you daily living?

What are your Goals/aims of Physiotherapy?