Please complete this before your first visit. It takes about ten minutes.
If you are reading this in your email app, tap the share or open-in icon and choose
Safari, Chrome or your usual browser. You can tick boxes and type here either way, but the
Save as PDF button at the bottom only works in a browser.
Why we ask. Your first appointment should be spent assessing and treating you, not
filling in paperwork. Knowing your history beforehand means the assessment can be planned
around your problem, and the time goes to you.
Your general health matters to your injury. Conditions such as diabetes, osteoporosis
or inflammatory arthritis change how tissues heal and how much load they tolerate. Some
medicines — blood thinners, corticosteroids, certain antibiotics — change which
treatments are suitable and how quickly a tendon or bone can be loaded. We only ask about
things that affect your assessment, treatment or rehabilitation.
A few symptoms need a doctor before physiotherapy. They are listed first. Tick one and
a note appears telling you what to do.
When you have finished, press Save as PDF at the bottom, then email the file to
admin@alliedhealth.net.au or bring it with you.
Your details
How your treatment is funded choose one
A few funding types need paperwork from you on the day. Choose yours and we will tell you what to bring.
Bring your health fund card and we will claim your rebate on the spot.
Please bring your current certificate of capacity. If you do not yet have a claim number, call us on 02 9518 3400 before the day so we can confirm the claim with your insurer.
Please bring your claim number and insurer's details. If your claim has not been lodged yet, call us on 02 9518 3400 before the day.
Please bring your DVA card and your GP's DVA referral. Treatment cannot be claimed through DVA without a current referral.
Please bring your GP's referral. The Medicare rebate cannot be claimed without it.
Your GP and referral
Check before your appointment tick only if it applies now
Most people tick none of these. If one applies to you, a note will appear telling you what to do.
Go to your nearest emergency department now. Do not wait for your physiotherapy appointment. These symptoms can mean pressure on the nerves at the base of the spine (cauda equina syndrome), which needs assessment within hours. When you can, call us on 02 9518 3400 and we will reschedule.
Call 000 now. Chest pain or breathlessness at rest needs emergency assessment. Please do not attend physiotherapy until it has been assessed.
Call 000 now. These can be signs of a stroke, and treatment is time critical.
Please see your GP or an emergency department today. These can be signs of a blood clot in the leg (DVT), which needs to be ruled out before the leg is treated or exercised. Then call us on 02 9518 3400.
Please see your GP or an emergency department before physiotherapy so the neck can be checked, and bring any imaging reports with you. Call us on 02 9518 3400 if you need to move your appointment.
Please see your GP before your appointment and let us know on 02 9518 3400. Pain with fever needs an infection ruled out first.
Please call us on 02 9518 3400 before your appointment. Worsening nerve symptoms are assessed as a priority, and we may ask you to see your GP as well.
Please call us on 02 9518 3400 before your appointment. This pattern is usually explained by something simple, but it is worth checking with your GP alongside physiotherapy.
Your main problem
Where is it? Tick every part involved, then choose the side.
Head and spine
Shoulder, arm and hand
Hip and leg
Ankle and foot
Other
Is this a fracture or a recent operation? Tick if it applies.
Please bring your X-ray reports and any discharge letter or fracture clinic instructions, including what you were told about weight bearing. If you need a backslab removed and a brace fitted, tell us when you book so the right time is set aside.
Please bring your surgeon's rehabilitation protocol or post-operative instructions, including any restrictions on movement or weight bearing.
Have you had any scans for this? Tick all that apply, and please bring the reports.
What treatment have you had for it so far? Tick all that apply.
Health history tap a heading to open it
Four groups. Tick only what applies — most people tick a handful at most. If you are unsure whether something counts, tick it; it is easier to set aside information we do not need than to find out later.
Medical conditionsshow
Anything diagnosed by a doctor, now or in the past, that may affect healing, exercise or treatment.
Please remind your physiotherapist on the day. Some electrical and magnetic treatments are not used with implanted cardiac devices.
Please remind your physiotherapist on the day. Some treatments and positions are adjusted during pregnancy.
Previous injuries and operationsshow
Medicationsshow
Medicines you take now. A few of these change which treatments are suitable or how quickly an injured tissue can be loaded.
Worth knowing. These antibiotics are linked to tendon pain and, rarely, tendon rupture, sometimes months after the course has finished. It changes how quickly we load a painful tendon.
Allergiesshow
Sport, exercise and work
How you train and what your work involves shapes the rehabilitation plan, so it fits your week rather than an ideal one.
Which types of exercise do you do? Tick all that apply.
Your goals
What would you like from physiotherapy? Tick all that apply.
Anything else you would like us to look at optional
Another injury, an old niggle, a second problem, or something you would like to discuss. Tell us here so time can be set aside for it.
Consent
Answers stay on this device until you save the file.
Inner West Allied Health & Specialist Centre · Suite 5, 267–277 Norton St,
Leichhardt NSW 2040 · 02 9518 3400 · admin@alliedhealth.net.au
Your information is kept confidentially in your clinical record and handled in line with the
Australian Privacy Principles. This form is not a medical assessment and does not replace advice
from your doctor. In an emergency, call 000.
