ACC / Private
If ACC, please enter claim number, date of injury, and case manager (if you have one)
Please check if you have ever been diagnosed with the following
CancerHeart ProblemsGastrointestinal disorderOsteoporosis / Low bone densityRheumatoid Arthritis or other rheumatoid conditionDiabetesDepression / AnxietyKidney diseaseStroke / blood clotsNone of the above
Please tick any of the following experienced in the last 2-4 weeks
FatigueGeneral feeling of unwellnessFever/Chills/SweatsNausea/VomitingNumbness, tingling or weakness in ANY part of the bodyDizziness / Light headednessChange in mental ability (e.g. confusion, memory loss)HeadachesNight PainSustained morning stiffnessTraumaConstipationEasy bruisingChanges in visionNONE OF THE ABOVE
In the last 4-6 months have you noticed any unexplained change in your weight?
Do you smoke?
Are you currently pregnant?
Do you have any new, unusual or atypical symptoms that are of concern to you?
List all medications that you are taking?
Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following?
CancerDiabetesHeart DiseaseStrokeNone of the above
Please list any surgery that you have had
I hereby give my consent to participate in physiotherapy sessions at ASC