Intake Questionnaire

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

1. Currently diagnosed health issues; *

2. Previous diagnosed health issues (i.e Cancer/Diabetes); *

3. Current prescribed medication; *

4. Please indicate your goals for seeking physiotherapy care short term; *

5. Please indicate your goals for seeking physiotherapy care long term; *

Body Chart

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

(We have also provided a decription box below the image, if you would like to provide further information)

Body Chart: *

Clear drawing

Further description:

Orebro Musculoskeletal Pain Screening Questionnaire

1. How long have you had your current pain problems? *

2. How would you rate the pain that you have had during the past week? *

3. I can do light work for an hour? *

4. I can sleep at night? *

5. How tense or anxious have you felt in the past week? *

6. How much have you been bothered by feeling depressed in the past week? *

7. In your view, how large is the risk that your current pain may become persistent? *

8. In your estimation, what are the chances you will be working your normal duties in 3 months? *

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.

9. An increase in pain is an indication that I should stop what I'm doing until the pain descreases? *

10. I should not do my normal work with my present pain? *

Total:

Patient Details

Title *

First Name *

Preferred Name

Last Name *

Gender *

MaleFemaleRather not say

Date of Birth *

Email Address *

Home Phone

Mobile *

Work

Address Line 1 *

Address Line 2

Suburb *

State *

Post Code *

Communication with our patients is our priority. Please mark your preferences: *

SMS (for appointment reminders)Email (so your physiotherapist can communicate with you regarding your treatment program and resources specific to your condition)Communication of upcoming appointmentsCommunication regarding special offers, conditions, treatments & general clinic announcements (our aim is to send relevant and important information to you)

Emergency Contact

Next of Kin

Relationship

Contact Number/s

GP Information

GP name

Clinic

GP Address

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)

Referrer Name

Referrer Clinic

Referrer Address

Employer:

Family and friends:

Study participant:

Social media:

Website:

Other:

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)

DVA Number (if applicable):

DVA Expiry Date:

Conditions covered by DVA for white card holders:

Motor Vehicle Accident (completed if applicable)

Date of Motor Vehicle Injury or Accident:

MVA Claim Number:

Insurance Company for MVA Claim:

Case Manager for MVA Claim:

Is liability for this claim current:

YesNo

Workers Compensation (complete if applicable)

Date of Workers Compensation Injury or Accident:

Workers Compensation Claim Number:

Workers Compensation Insurance Company:

Case Manager for Workers Compensation Claim:

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.

Health Statement

For the safety of our staff and patients, if you are unwell or experiencing any cold or flu symptoms, we ask that you contact us to reschedule your appointment.

ALL PATIENTS PLEASE READ AND SIGN

DECLARATION: I understand and agree that:

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.
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 fees maybe added.
In the event that my accounts are outstanding longer than 45 days, I will be responsible for all collection fees incurred.
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.
I consent to treatment provided by the clinicians.

Any comments in regards to your appointment:

Documents relating to your appointment:

Browse

Signature *

Draw signature|Type signatureClear

Date: