AppointmentComplaintsDescribe your physical complaints, stating limitations in movement, activities.Describe your pain in terms of location, quality (sharp/burning/dull/pins and needles etc).When did the symptoms start?Can you state what might have caused the complaints?Have you had an episode of similar symptoms in the past and if so how did they resolve and for how long?Were there any specific events or experiences in your life prior to the onset of your symptoms?Did you receive any kind of treatment for the complaints yet and if so what was the effect of treatment (please state treatment)?Medical HistoryHave you undergone any form of surgery in the past (please also state possibly unrelated surgery and small ones, stitches included)?Do you have any scars and if so please state where (tattoos and piercings as well)?Did you ever break any bones, tore ligaments or had big bruisings (please state where)?Are there any health issues in your family that are hereditary?Is there anything physical you would like to mention (not asked in the previous questions) that might contribute to your symptoms?MedicationAre you taking any kind of medication or supplements (please state which ones)?Do you have allergies or intolerances, if so please state for what and what symptoms these provoke?Mental HealthHave you ever received treatment for Psychological or Emotional issues? If so please state when and kind of treatment.Do you worry a lot or experience any Anxiety?Could you rate your Mental Health on a scale of 1-10 (1 being miserable, 10 being perfect)?0SleepDo you sleep well?Please rate the quality of your sleep on a scale of 1-10 (1 being miserable, 10 being perfect).0Physical ActivityWhat physical activities are a part of your weekly life?Do you participate in any Sport or do you have Hobbies (please state which and how many hours a week you spend on them)?WorkWhat is your Profession/Line of work?How many hours a week do you spend on work?Please rate the perceived quality of your work environment on a scale of 1-10 (1 being miserable, 10 being perfect).0Email AddressSend
