Patient Registration - Physiotherapy clinic in Hadleigh, South Essex

Personal & Contact Details

We will use this information to register you at our clinic and contact you as required

Name*

Title Forename(s) Surname

Preferred Name*

Address*

Street Address Address Line 2 City County Postcode

Date of Birth*

Please provide in DD/MM/YYYY format

Gender*

Home Phone*

Work Phone

Mobile Phone

Email Address*

Occupation*

Next of Kin*

Relationship to you*

Next of Kin Contact Number*

GP / Consultant Details

This allows us to communicate information about you with your doctor.

GP*

Consultant

GP Medical Centre*

Financial/Insurance Details

Required to invoice insurance companies/process your payments.

Payment Type*

If you are paying for your treatment and then claiming back through your insurance company please select tick this box

If you are paying for your treatment please select tick this box

Insurance Company

Policy Number

Authorisation Number

The reason for your visit

This helps us to get the best outcome from your session

When did the condition begin?*

Is the condition getting worse?*

Yes

Staying the same

Coming and going

What would you like to get out of this and any subsequent appointments?*

Do you have any specific goals or targets? (holidays, sporting events, functional challenges eg: mowing the grass)*

What activities, postures/positions aggravate your current problem? Please list as many as possible.*

Have you ever visited a physio/osteopath/chiropractor?*

If yes what would you change about the experience

Your Health History

Giving these details allows us more time to examine and treat you. To save time during your consultation please answer the following medical questions, the information you provide will remain confidential.

Heart Disease/Surgery*

Yes

High Blood Pressure*

Yes

Diabetes*

Yes

Rheumatoid Arthritis*

Yes

Asthma*

Yes

Epilepsy*

Yes

Cancer*

Yes

Tuberculosis*

Yes

Stomach Ulcers*

Yes

Depression*

Yes

Dizziness*

Yes

Double/Blurred Vision*

Yes

Fainting spells*

Yes

Problems swallowing / speaking*

Yes

Bladder problems*

Yes

Unexplained weight loss*

Yes

Bowel Problems*

Yes

Lower back problems*

Yes

Frequent Headaches*

Yes

Neck problems*

Yes

Are you taking any of the following*

Pain killers

Muscle relaxants

Blood thinners (anti-coagulants)

Anti-inflammatories

Steroids

Insulin

None of the above

Please list any other medication you are taking

Are you wearing?*

Heal lifts

Orthotics

Arch supports

None of the above

Do you use special pillows?*

Please state what type

Do you use a computer?*

Please state how many hours per day

Do you take regular exercise?*

Yes

If yes, how often per week?

Marketing

We like to know how you found us.

Please tell us how you found us*

Google

Facebook

Instagram

YouTube

Paid Sponsor/Advert

Other

How could we improve our website?

Recommendation/Referral/Other

Data Protection

Movement Matters Physio understands that your personal data is entrusted to us and appreciates the importance of protecting and respecting your privacy. Our privacy policy can be found on our website at https://www.movementmattersphysio.co.uk/privacy-policy

Please tick this box to indicate that you have access to and are aware of our privacy policy

To enhance your experience at Movement Matters Physio we would like to use your personal information to send you details of: appointment confirmations and reminders, receipts for treatment and products, instructions on how to review our services and copies of any letters sent to your doctor. This is normally via email but on occasions by post or SMS text message.

Communication Policy*

Please tick this box to indicate that you are happy to be contacted in this way

We would like to send you information such as; tips to stay healthy and pain free, special offers that we are running, news or upcoming events that we are holding (eg: free seminars) and information about our products and services by post, telephone, email and SMS. If you agree to being contacted in this way, please tick the relevant boxes. We promise to provide you with quality information, not to spam you or share your details.

Communication Preference

Post

Telephone

SMS Text

Date*

Signature*

A parent or guardian should sign if the patient is under 18 years of age.