Self-referral to physiotherapy specialist
Family name _______________________________ First name ______________________________
Social security number _______________-__________
Date ___.____20__
Address _______________________________________________________________________
Phone number (home)___________________ Phone number (work)______________________
How long has your present ailment lasted? ________ months ________ days
Date of the accident ____.____. 20___. Insurance company: ______________________________
(Only fill this in if the visit is about an accident that is covered by your insurance)
GENERAL HEALTH
Height ________ cm
Weight _______ kg
Illnesses, surgeries and injuries _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Medications (name and dose) ______________________________________________________
______________________________________________________________________________
Smoking
no
yes, an average of _____ cigarettes / day
Drinking
no
yes, an average of _____ days / week,
_____ servings at a time
(One serving = one bottle of medium strength beer, 12 cl wine or 4 cl spirits).
Pain
no
intermittent
continuous
Pain
no
on exertion
at rest
No
Difficulty in sleeping
Tiredness during the day
Nervousness, anxiety or tenseness
Inability to control or stop worrying
Many
days
Most
days
Almost
daily
Mark the places where you have had symptoms during the last week.
ache, pain
(mark with xxxxx)
numbness, stiffness
(mark with ooooo)
insensibility
(mark with IIIIIIIIII)
RIGHT
LEFT
LEFT
RIGHT
Mark on the lines below the severity of the pain you have felt during the last week.
Use vertical lines as markers.
No pain
Back pain
Neck pain
Headache
Upper limb pain, right
Upper limb pain, left
Lower limb pain, right
Lower limb pain, left
Chest pain
Stomach ache
Worst possible pain