Physiotherapy assessment

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

Is your pain in 3 or more areas of your body?

Yes

No

If you have pain in 3 or more of your body parts, please book an appointment with a doctor.

Where is your pain?

Do you feel generally unwell, feverish or have you had a recent infection within the past week or so?

Yes

No

Please book an appointment with a doctor.

Have you attended a pain clinic regarding this issue before or are you currently seeing a specialist about this issue (including but not limited to Rheumatologist, Orthopaedics, MSK clinic)?

Yes

No

Please book an appointment with a doctor.

Have you ever been diagnosed with a condition such as Rheumatoid arthritis, Fibromyalgia or chronic fatigue syndrome?

Yes

No

Please book an appointment with a doctor.

How long have you had this problem for?

If you have had this problem for more than 8 weeks, please book an appointment with a doctor.

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