Pre-Consultation Questionaire

Thank you for booking with Sports Medicine Institute

PRE-CONSULTATION INFORMATION

To assist with your consultation, we kindly ask that you complete as many questions as possible in the space provided below.

Title

First Name *

Surname *

DOB *

Medical Problems - List issues, when diagnosed, started, occurred. *

Surgery - type of surgery, surgeon, date, issues, medication taken *

Current Medication List *

Immunisation Status if under 18 *

Known Allergies *

Alcohol Use *

Family History of Medical Problems

Occupational/Education History *

Sport & Exercise

Hand Dominance *

Foot Dominance *

Chronology of Injury - date of injury/onset

Mechanism of Injury

Severity out issue (zero=normal, 10=worse ever)

Exacerbating & Relieving Issues

Effect on Work

Effect on Sport

Effect of Activities of Daily Living

Current Status - % of Improvement

Treatment including dates – GP, medications, injections, physical therapies, specialists, and any improvements ( as a % )

Previous Investigations eg. Radiology/Pathology, type, date, where was it done?