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

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