Pre-assessment and treatment questionnaire - Physiotherapy and ...

Pre-assessment and treatment questionnaireThe following questions aim to guide you when writing down your medical and injury history. We willdiscuss this at your first session and the information will help to direct the assessment. If you are unsureof an answer just put a question mark (?) and we can go over the question more thoroughly together.Some of the questions may seem irrelevant but I will explain the association of these symptoms duringyour session.Name: Date of Birth: Contact N#:Address:.............................................................................................. Today’s Date:1. Please describe your current symptoms?2. In chronological order, summarise past injuries – date, accident and injury, e.g. 1991, fell out oftree, right wrist fracture and concussion.3. In chronological order, summarise past illnesses such as tonsillitis, glandular fever, hospitaladmissions, allergies and bad periods of asthma or hay fever.4. Have you ever had any treatment for your pain/symptoms? If yes, who was this from and did ithelp?5. What makes your pain/symptoms worse?6. What makes you pain/symptoms better?7. Do you ever get pins and needles or numbness in your arms or legs?8. Do you ever get pain in your joints?9. What is your pain like at night, are you sleeping alright?10. How do you feel when you wake up in the morning? – Pain, tiredness, stiffness, pins and needles,numbness or weakness?

11. Are you taking any medication? – Blood pressure, cholesterol, anti-inflammatory medication?12. Are you taking any vitamins or supplements?13. Have you had any investigations for your problem such as an x-ray, ultrasound, and a blood test,MRI or CT scan?14. Do you suffer from headaches or migraine? If yes, how long have you suffered from these? Wasthere a particular incident that set them off? How often are you having them at the moment?15. Do you ever have dizzy spells or faint attacks? – This includes feeling dizzy if you stand up tooquickly?16. Do you ever have a racing heart, palpitations or chest pain?17. Do you get tired easily?18. Do you get easily stressed up or anxious?19. Have you ever had panic attacks or depression?20. Do you suffer from indigestion?21. Do you suffer from any other symptoms in the stomach and bowels such as irritable bowelsyndrome, abdominal pain, bloating, indigestion, constipation or diarrhoea?22. How would you describe your general health? – do you suffer from constant coughs or colds? Orother infections such as urinary tract infections, thrush, sinusitis, ear infections?23. Do you suffer from muscle cramps in your legs and/or feet? Do these occur during the night ordaytime?24. Do you suffer from cold hands and/or feet?25. Do you have any trouble with the roots of your teeth?26. Is there anything else that you think may be relevant to your current problem?Kate Bonner @ Physiotherapy and Pilates Evolved LtdPhone: (03) 384 4766 Fax: (03) 384 4767Email kate@physioevolved.co.nzP a g e | 2