Client Pre Assessment Forms

All of the information supplied below will be treated confidentially and will only be used by Connect Neuro Physiotherapy for your private consultation.

    YOUR INFORMATION

    Your Name

    Your Email

    Date of Birth

    Address

    Telephone

    Mobile

    GP / Doctor's Details

    Specialist Doctor's Details

    How did you hear about Connect Neuro Physiotherapy?
    WebsiteFacebookWord of mouthConference/PresentationReferral
    Details of how you heard about us

    Diagnosed Neurological Condition (Main diagnosis to be discussed during consultations):

    What are your main issues, concerns, problems?

    What is your expectation from therapy?

    What are your therapy goals?

    MEDICAL HISTORY

    Please mark any of the following if they are relevant to you:
    Heart issuesBlood pressureRespiratoryNeurologicalShortness of breathCancerDiabetesEpilepsyRecent surgeryChronic PainArthritisOsteoporosisFractured / broken bonesJoint replacementsBladder and/or bowel issues/changesLightheadness and/or dizzinessVisionHearingDepressionAnxietyAny surgeryAny recent change in medication

    Number of falls and near misses in the last 6 months?

    Any other medical issues or concerns that I should be aware off?

    Current medication list?

    Apart from your Doctor what other health professionals have you seen for your condition or currently see?

    SOCIAL HISTORY

    Current employment?

    Living situation, e.g. alone, with family, in a house, unit, nursing home?

    Do you receive any assistance with daily tasks, including cooking, cleaning etc?
    YESNO

    What do you do for regular exercise?

    Any other hobbies or activities you do on a regular basis?

    Do you give consent for information to be sent to your Doctor regarding your therapy plan from Connect Neuro Physiotherapy?
    YESNO

    Do you consent for therapy plans, exercise programs, and educational material for example to be emailed to you?
    YESNO

    Would you like to receive Connect Neuro Physiotherapy’s quarterly newsletter by email?
    YESNO

    By submitting this form you have consented to receive neurological physiotherapy advice and treatment from Connect Neuro Physiotherapy. THANK YOU.