PhysioPreConsult

PRE-CONSULTATION FORM

APPOINTMENT DATE *

APPOINTMENT TIME *

Do you consent for your physiotherapist to communicate with your GP regarding the care provided? *

YES NO

What brings you to the dietitian today and what would like to achieve? *

Medical conditions? *

Medications? *

Do you smoke? *

YES NO

Do you drink alcohol? *

YES NO

Do you take any recreational drugs? *

YES NO

How often do you exercise? *

Never Once a week 3-5 Times a week Everyday

Sleep most nights? *

8+ Hours 6-8 Hours < 6 Hours

Sleep quality most nights? *

Good Fair Poor

Submit