Personal information

First name

Last name

Email

Phone

Address

Postcode

Birthday

Day

Month

Year

Occupation

Next of kin

Name

Phone

Medical history

Have you had a recent/past injury?

No

Yes

Have you had a recent/past surgery?

No

Yes

Do you suffer from a chronic (lasted longer than 3 months) musculoskeletal condition?

No

Yes

Are you taking any medication?

No

Yes

If you selected any of the above, please provide details:

Current lifestyle

Are you doing any regular exercise?

No, I am not currently exercising.

I do occasional light activity (e.g., short walks, gentle stretching, household chores).

I exercise 1-2 times a week (e.g., brisk walking, yoga, swimming, cycling).

I exercise 3-4 times a week (e.g., gym workouts, running, group classes, sports).

I exercise 5 or more times a week (e.g., high-intensity training, regular sports, endurance training)

Other

Do you smoke?

Do you drink alcohol?

Final details

Have you been pregnant in the last 6 months?

Not applicable

No

Yes

Is there anything else you’d like to share about yourself?

And one last question...

Declaration

I confirm that I have completed this form to the best of my knowledge and understand that it is my responsibility to inform my physiotherapist of any important medical information or changes in my health

Yes

Signature

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