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Name
*
Email
*
Address
*
Phone
*
What is your main concern today?
*
Pain
Injury
Stiffness
Weakness
Post-surgery rehab
Other
Where is the problem?
*
Neck
Shoulder
Upper back
Lower back
Hip
Knee
Ankle/foot
Arm/hand
Other
How did it start?
*
Sudden injury? (Sports/fall/lifting)
Gradual onset (Came on over time)
Post-surgery
Unknown
Other
How long have you had this issue?
*
0-3 days
4-7 days
1-4 weeks
1-3 months
3+ months
Other
Pain score (0-10)
*
0-4 (mild)
5-7 (moderate)
8-10 (severe)
Other
What does it feel like?
*
Sharp
Dull/aching
Burning
Stiff/tight
Shooting/electric
Weakness
Other
What is it affecting most?
*
Walking
Work
Sport/exercise
Sleep
Daily activities
No major limitation
Other
What makes it worse?
*
Movement/exercise
Sitting
Standing
Lying down
Lifting
Nothing specific
Other
What helps it feel better?
*
Rest
Heat
Ice
Movement
Medication
Nothing helps
Other
Have you had this before?
*
Yes - same area
Yes - different area
No
Other
Do you have any of the following?
*
Numbness/tingling
Weakness in limb
Recent fall or trauma
Fever/unwell feeling
None of the above
Other
What is your main goal?
*
Pain relief
Return to sport
Return to work
Improve mobility
Prevent injury
General health/fitness
Other
What service do you prefer?
*
Mobile service
Telehealth
Anything else to provide...
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