Patient Details

Emergency Contact

GP Information

Referrer Information (if different from GP information)

Please tell us who to thank for referring you to our clinic

(if different from above GP details)

The below information is for patients being seen under workers compensation, department of veterns affairs or motor vehicle accident. 

If the below does not apply to yourself, please continue to the next and final page. 

Thank you. 

Department of Veteran Affairs (complete if applicable)

Motor Vehicle Accident (completed if applicable)

Workers Compensation (complete if applcable)

Privacy Statement

Your personal health information and your Records may be collected, used and disclosed, including but not limited to, the following reasons: 

  • For communicating relevant information with treating doctors, specialists, insurers or other allied health professionals

  • For use by all clinicians in this group practice, when consulting you

  • For research purposes (de-indentified, meaning you are not able to be indentified from information given)

If you have any concerns or wish to restrict access to your personal health information, please discuss these with your treating clinician. 


DECLARATION: I understand and agree that: 

  1. If I am unable to attend my appointment I will give 24 hours notice of my cancellation. If I do not cancel with notice I will be charged a Non-Attendance Fee for my missed appointment. 

  2. I am required to pay on the day for all consultations. Body Logic Physiotherapy accepts, cash, cheques and has EFTPOS and HiCaps facilities. If my account is not paid at the time of consultation, administration feed maybe added. 

  3. In the event that my accounts are outstanding longer than 45 days, I will be responsible for all collection fees incurred. 

  4. For insurance claims, I will be personally responsible for payment of all accounts incurred by me in the event that liability is denied, or placed in dispute by the insurance company.  

  5. I consent to treatment provided by the clinicians.

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Intake Questionnaire

Please answer the following questions to ensure that we have a thorough understanding of your past and current heath.

Body Chart

Please look at the image below and mark any areas of pain and/or pins and needles and altered sensation.

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Orebro Musculoskeletal Pain Screening Questionnaire

Here are some of the things which other people have told us about their pain. For each statement please select one number from 0-10 to say how much physical activities, such as bending, lifting, walking or driving affect your pain.