Patient Questionnaire

Please detail the following:

Do You have a history of any of the following?
Diabetes	YesNo
Heart conditions	YesNo
Rheumatoid arthritis	YesNo
Cancer or tumours	YesNo
Epilepsy or fits	YesNo
Asthma	YesNo
Headaches or migraines	YesNo
High blood pressure	YesNo
Bladder or Bowel disorders	YesNo
Nerve disorders or neurological conditions	YesNo
Digestive problems	YesNo
Blackouts	YesNo

Please detail any medication you have taken during the past year

Have you ever had any fractures, (broken bones), dislocations/joint problems?

Surgery (operations)

Hospital stays (please detail)

Please detail the condition you are seeking help from the Physiotherapist for

Are you taking any of the following medications:

SteroidsYesNo

PainkillersYesNo

Anti-Inflamitory MedicationYesNo

Your full name
	I confirm that the above information is accurate