Pre-Appointment Screening Form

You can book an appointment with Harding Physiotherapy by calling the clinic on 01487 843 844 or emailing info@hardingphysiotherapy.co.uk.

Prior to your appointment, please complete the Pre-Appointment form below. This information helps us to carry out our risk assessment, but more importantly helps us to understand more about why you contacted us, which enables us to allocate you to the therapist best placed to meet your treatment requirements.

If calling the clinic we can go through this form with you over the phone.

YOUR CONTACT DETAILS

Full Name:

Birth Date:

Telephone Number:

eMail Address:

ABOUT YOU

Are you in generally good health?

Please describe any health issues.

Do you take any medication?

Please list any medications that you take.

ABOUT YOUR CURRENT PAIN / INJURY / SYMPTOMS

Tell us why you have booked an appointment

Where is your pain?

How and when did it start?

Have you noticed anything that makes it feel better or worse?

Does it affect your sleep/work/hobbies/daily life/sport/ability to care for yourself or other dependants? The more detail you can give, the better please:

Have you been to the GP or hospital with this pain or symptoms?

Please detail any related GP Visit.

Treatment Cover:

If using Private Health Insurance please provide company name and treatment authorisation number:

Your data will be processed in accordance with our Privacy Notice and medical best practices.

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This form will be sent to our team when you click 'submit'.

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