Telehealth Physio Appointments

Telehealth Injury Screening Form

Name

Date of Birth

Phone

When did it start? Was there a moment in time when your pain started or was the onset more gradual?

Have you experienced this before?

Have you experienced any recent significant trauma e.g. falls / car accidents?

Rate your pain on a scale of 0-10 (0 = no pain, 10 = worst pain imaginable):

Please describe where you a feeling most of your symptoms:

What aggravates your symptoms?

Is there anything that provides relief?

What is your Occupation?

Do you participate in any sports / hobbies / other regular activities?

Medical History:

Previous Surgical history:

Any other information you think may be helpful: