Pre-Physio Medical and Consent

Before your first appointment with us please fill out the following form.

ACC / Private

ACC Private

If ACC and you know any details of the claim number, date of injury, and case manager, please enter below

Currently Working

Yes No

Work Type

Sedentary Light Medium Heavy Very Heavy

Living Situation

Alone With partner/spouse Other

Please check if you have ever been diagnosed with the following

Cancer Heart Problems Gastrointestinal disorder Osteoporosis / Low bone density Rheumatoid Arthritis or other rheumatoid condition Diabetes Depression / Anxiety Kidney disease Stroke / blood clots None of the above

Please tick any of the following experienced in the last 2-4 weeks

Fatigue General feeling of unwellness Fever/Chills/Sweats Nausea/Vomiting Numbness, tingling or weakness in ANY part of the body Dizziness / Light headedness Change in mental ability (e.g. confusion, memory loss) Headaches Night Pain Sustained morning stiffness Trauma Constipation Easy bruising Changes in vision None Of The Above

In the last 4-6 months have you noticed any unexplained change in your weight?

Yes No

Do you smoke?

Yes No

Are you currently pregnant?

Yes No

Do you have any new, unusual or atypical symptoms that are of concern to you?

Yes No

Has anyone in your immediate family (parents, brothers, sisters) ever been treated for any of the following?

Cancer Diabetes Heart Disease Stroke None of the above

I hereby give my consent to participate in physiotherapy sessions at ASC. I understand that these sessions will be either face-to-face or via the internet

Yes