Do Your Daily Activities Involve Lifting Or Physical Strength? Yes/No

Do Your Daily Activities Involve Lifting Or Physical Strength? Yes/No

Surname:Title:

First Name:

Emergency contact:Ph:

Occupation:

What % of the day do you spend:

Sitting; Standing; Moving;

Do your daily activities involve lifting or physical strength? Yes/No

Do your daily activities involve a lot of repetition? Yes/No

How much exercise do you get per week?

Type/s of physical activity:

Current Fitness level:

How did you hear about this practice?

(As Applicable)

Legal Guardian (if under 18years of age):Ph:

Private Medical Insurance Fund:DVA Number:

Referring Doctor: GP:

Pension Number:

Insurance claim number: Date of accident: / /

Cardiovascular System

Yes / No
Do you have any heart problems?
Do you have peripheral vascular disease?
Do you have any lung conditions?
Are you taking medication for high blood pressure?
Do you have any blood clotting or platelet problems?
Do you have a pacemaker?
Have you ever had a stroke?
Have you been or are you currently a smoker?
Are you currently taking any blood thinning medications?
Have you had a heart valve replacement?

Medical Issues

Do you have Type I or Type II Diabetes?
Have you had any significant weight changes in the past twelve (12) months?
Do you have epilepsy?
Have you had cancer of any kind?
Have you had surgery for cancer?
Are you pregnant or could you be pregnant?
Have you been diagnosed with anxiety or depression?
Recent major illness?
Recent surgery?
Are you immunosuppressed?
Have you ever had TB?

Screening questions

Do you have numbness or pins and needles in any part of your body?
Have you experienced dizziness, visual disturbances or black outs at any time?
Have you had speech or swallowing difficulties?
Have you had trouble emptying your bladder?
Have you experienced any problems with walking?
Do you have any balance problems?
Does your pain decrease with rest?
Do you have any weakness in your legs?

Bones and Joints

Yes / No
Do you have osteoporosis?
Do you have osteoarthritis / rheumatoid arthritis / other?
Have you ever had bone or joint surgery?
Do you have any orthotics?

Other

Have you ever had a reaction to adhesive tapes/bandages?
Are you allergic to metal?
Do you have any problems with your hearing?

List of current Medications (if known) NB Blood thinners and steroids

Type / Dose / Effect

Please Initial Below to Confirm That you Have Read and Understood the Following:

  1. 24 hours cancellation notice is required. A fee is generated with less than 24 hours cancelation notice. Initial: ______
  1. Please be aware that health funds will NOT cover non-attendance for treatments.
    Initial: ______
  1. Please be aware that you may experience some post treatment soreness (any concerns, please speak to your physiotherapist). Initial: ______

Patient Specific Functional Scale:

List and score 3 functional activities that you currently have the most difficulty with on the lines below. (E.g. combing your hair, buttoning up a shirt, driving, sitting/standing)

Functional Activity 1:______

Functional Activity 2:______

Functional Activity 3:______

Peta Murphy BPhty MMACP MAPA | Principal Physiotherapist | 0407 158 429 |

Top View