Consultation Form | Warrington Pain Clinic

Prefix

First Name *

Last Name *

Email Address *

Phone

Age *

GenderFemaleMalePrefer not to say

Street Address

Apartment, suite, etc

City

State

Postal Code

Country

Emergency Contact Name

Emergency contact number

Are you currently suffering from any physical pain / mental pain or sleep deprivation? *NoYes

Please select all that apply *Physical painMental painSleep deprivation

Please describe the pain in your own words *

Where in the body is your pain located? *

On a scale of 1-10, please average your pain intensity over the last 2 days in your worst area* *

How do your symptoms behave throughout the day? Are they worse in the morning or at night?

When did the symptoms first appear, did anything significant happen at the time?

PAIN ON WALKING - Please indicate the level of reduced activity *InstantlyAfter 10 minutesAfter 30 minutesMore than 60 minutes

DRESSING SELF - Please give more details on which item of clothing you are struggling with *

Does any activity, movement or posture ease these symptoms? *

STAIRS - please indict pain triggering action *Up stairsDown stairsSide ways up stairsSide says down stairs

DRIVING - Please give more details *

STANDING ON ONE LEG - Please indicate which leg *Standing on you right legStanding on your left leg

STANDING - Please indicate the level of reduced activity *InstantlyMore than 10 minutesMore than 30 minutesMore than 60 minutes

SITTING - Please indicate the level of reduced activity *InstantlyMore than 10 minutesMore than 30 minutesMore than 60 minutes

HOUSE WORK - Please give more details on the tasks which trigger pain *

WORK TASKS - Please give more details on the tasks which trigger pain *

SPORTS - Please give more details on which sports and how your symptoms are triggered *

OTHER - Please give more details on the tasks which trigger pain

Have you had any medical treatment / assessment for these symptoms?

Do you have difficulty lying on your front, back or side?NoYes

Please give details

Do you have any allergies or sensitivites?NoYes

Please give details *

Are you pregnant?NoYes

How many weeks pregnant? *

Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

Draping will be used during the session - only the area being worked on will be uncovered, everything wrote and discussed in your consultation and treatment is confidential.

I confirm that the information provided is correct to the best of my knowledge. I further understand that thorough open and honest responses to questions are essential to my safety. If there are any changes to condition I will notify the therapist at the earliest opportunity. I understand all treatment methods will be explained to me. I give consent & I’m happy to proceed with treatments.

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