Nick Ilic Physio Clinician - Pre-Consult Questionnaire

Pre Consult Questionnaire

Please fill this form out with as much detail as possible. It will allow us to recommend the most appropriate and cost-effective service for you.

About you
The more we know about you, what you do for a living and what you do for fun/exercise, the more we can help you reach your goals.
Title - Mr/Ms/Mrs/Miss/Dr
Full Name*

First NameLast Name
Mobile/Phone Number*
So we can call you back to arrange a time
Date of Birth*

DayMonthYear
Date of Birth
Please select your timezone*
Email*
example@example.com
Occupation*
Be Specific. Full-time/Part-time/Casual? Do you study? What do you study? Retired?
What sports, exercise activities and/or hobbies are you into? How often do you do these throughout the week? *
Play sport? What level? Do you train? What days do you train and compete?
Do you have any specific goals for this consult?
Are there any important events coming up in the near future (2-3 months)

The reason for your consult
'The diagnosis is in the story'. Please fill in as much of this section as possible as it really does assist us in finding out what is going on so we can make a solid plan.
Is this a new, old or recurring injury?*

NewOldRecurring
Please draw on the image where your injury(s) is/are. Be as precise as possible as this can really help with getting the diagnosis right.
When did the pain/discomfort start or when was the original injury?*
X Weeks, X Months, X Years, Not Sure
Have you had this injury before? When?*
How long did it take to settle down? Did you receive treatment
How would you best describe your pain/discomfort?*

AchingCrampingFearfulGnawingHeavyHot or burningSharpShootingSickeningSplittingStabbingPunishing or cruelTenderThrobbingTightnessTiring or exhaustingOther

How irritable is your pain/discomfort?*

	1	2	3	4	5

1 is Mild, 5 is Severe

If your pain/injury is related to a joint (knee/hip/shoulder) do you have any of the following symptoms?

WeaknessStiffnessFeels unstableClickClunkPop
Does anything make your pain/discomfort feel better?
What makes your pain/discomfort feel worse?
Especially comment on Daily Activities such as cooking, cleaning, dressing, driving, working etc. Does your go away after a while. How long does it take for the pain to start. How long does it take for the pain to settle aftewards.
Does your pain have a pattern over the day/night?
Is it worse in the morning, the evening, does it wake you up at night?
Do you have Pins and Needles?*

YesNoNo sure
Have you had any diagnostic imaging for this injury*

Yes (upload any reports below)No
Do you have any previous reports or diagnostic imaging for this injury? Upload them here

Browse Files
Upload any documents, reports or imaging reports related to your injury. Cancelof

Neck / Back / Trunk Self-Assessment
If you are only experiencing Neck, Trunk/Chest or Low Back Pain please complete this part of testing. If you are experiencing trunk/chest/midback pain please complete BOTH 'Neck' and 'Lower Back' assessment tasks.

The tasks are listed in order from least likely to most likely to challenge your injured area. If painful at any stage, feel unsafe/uncomfortable completing any task do NOT continue with the rest of the list.

You can make any relevant comments in the comment box below the table.

Neck Self-Assessment Tasks (also complete for trunk/chest/mid-back)

Back Self-Assessment Tasks (also complete for trunk/chest/mid-back)

	No Pain	Mildly Painful	Moderately Painful	Very Painful	Not tested
In Standing, bend over (hands sliding down front of legs), comment (in comment box below table) how far until you had pain (thighs/knees/shins/feet)
In Standing, holding onto hips, lean backwards
Whilst sitting, turn your trunk left
Whilst sitting, turn your trunk right
Lying supine (on back), lift up your left leg
Lying supine (on back), lift up your right leg
Walking 5m
Sitting > 5mins
Squatting

Lower Limb Injury Self-Assessment
If you are experiencing hip, knee, ankle/foot or lower limb pain please complete this part of testing.

The tasks are listed in order from least likely to most likely to challenge your injured area. If painful at any stage, feel unsafe/uncomfortable completing any task do NOT continue with the rest of the list.

You can make any relevant comments in the comment box below the table.

Lower limb Self-Assessment Tasks

	No Pain	Mildly Painful	Moderately Painful	Very Painful	Not tested
Walking
Squat
Light Jog
Jog
Run
Step up on chair
Step down from chair
Squat walk
Hopping on spot
Hopping 5m
Sprint 10m with sudden deceleration

Upper Limb Injury Self-Assessment
If you are experiencing shoulder, elbow wrist/hand or upper limb pain please complete this part of self testing.

The tasks are listed in order from least likely to most likely to challenge your injured area. If painful at any stage, feel unsafe/uncomfortable completing any task do NOT continue with the rest of the list.

You can make any relevant comments in the comment box below the table.

Upper limb Self-Assessment Tasks

	No Pain	Mildly Painful	Moderately Painful	Very Painful	Not tested
Lift arms above head
Fully bend elbows
Full straighten elbows
In hand-shake position (thumb up) grip a rolled up pair of socks as hard as possible
With palm facing down (knuckles up) grip a rolled up pair of socks as hard as possible
Wall Pushup
Hold yourself in a high-plank – pushup start position (don’t do a pushup)
Hold yourself in a single hand high-plank position
Do a full pushup

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How did you find out about this service?*

Existing ClientDoctor/ReferrerSearch Engine (eg: Google)WebsiteSocial Media (Facebook, Instagram etc.)Other
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Pre Consult Questionnaire