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Berrylands Sport Rehab

New Client Rehabilitation

Please complete the following questions as accurately as you can.

Any information will be treated in the strictest of confidence.

First Name

Surname

Email Address

Date of birth

Phone

Occupation

Address

How did you hear about Berrylands PIlates e.g.Facebook, Google search, friend,poster etc?

Present Condition: What are your current symptoms?How did your symptoms start? Date of injury.Aggravating factors. Relieving factors.

Past Medical History: Are there any significant medical events in your life?

Previous Treatments

Investigations (MRI, X-ray, tests)

Do you have or have you ever had any of the following conditions:

Heart Condition

High/Low Blood Pressure

Diabetes

Asthma

Bowel/Bladder Disorder

Epilepsy

Surgical Procedures

Anasthesia

DVT(Deep Vein Thrombosis )

Parasthesia( Pins and Needlee)

Metal /Plastic in Tissue

Cancer

Are you currently taking any prescribed medication?

No

Yes

If you have answered YES to any question, please give more details

Full Name

Today's Date

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