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Physiotherapy
New Patient Registration Form
Mackay
Date: _______________________
Draw on the sketch below the area where you feel your problem to be.
How long have you had this problem? ________________________________________________________________________________
Have you had this or a similar problem in the past? _____________________________________________________________________
¨ Constant
¨ Intensity Varies
If you are experiencing pain, please tick the words that best describe your pain:
¨ Sharp
¨ Travels
¨ Achy
¨ Comes and Goes
¨ Radiates
¨ Intensity Doesn’t Vary
¨ Pins and Needles
¨ Tingling
¨ Numbness
¨ Weakness
Do you get:
¨ About the Same
¨ Getting Better
¨ Getting Worse
Since the problem started, is it:
¨ Sitting
¨ Standing Up
¨ Walking
¨ Other:_____________________
Which activities make your pain worse:
Do you generally feel healthy? Please list any problems with your general health: _____________________________________________
________________________________________________________________________________________________________________
Previous conditions or operations: ___________________________________________________________________________________
Other health professionals seen for this problem (please list):
¨ Medical Doctor
¨ Specialist
¨ Surgeon
¨ Chiropractor
¨ Massage Therapist ¨ Bowen Therapist ¨ Other: _______________________________________
Name: __________________________________________________________________________________________________
List any medications you are taking: __________________________________________________________________________________
Do you have or have you ever had? ¨ High blood pressure
¨ Bladder or bowel difficulty
¨ Heart problems ¨ Strokes
¨ Diabetes
¨ A pacemaker
¨ An aneurysm
¨ Osteoporosis
¨ Cancer
¨ Rheumatoid arthritis
¨ Ankylosing spondylitis ¨ Psoriatic arthritis
¨ Reiter’s arthritis
¨ Pregnant
¨ Spinal trauma ¨ Spinal fracture
¨ Spinal surgery
¨ Recent nausea /feeling unwell
¨ Dizziness
¨ Dislocations
¨ Ligament injuries
¨ Cartilage injuries
¨ Osteoarthritis
¨ Unexpected weight loss ¨ Taken steroids /oral cortisone/prednisolone
Details: _________________________________________________________________________________________________________
Phone: 07 4953 3557
169 Shakespeare Street
33 Central Street
Terminus Business Park
Mackay Q 4740
Sarina Q 4737
Unit 6, 32 - 34 Caterpillar Drive Paget, Q 4740

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