Preassessment

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Name(Required)

First Last

Email(Required)

Date of Birth(Required)

Day

Month

Year

Address

Street Address Address Line 2 City County / State / Region Eircode Country

Phone(Required)

Occupation

Main Reason for your appointment:

Areas of complaint, pain or tension(Required)

When did you first notice this complaint?(Required)

Is this complaint getting ...(Required)

Better

Worse

Same

Is the condition interfering with your...

select all that apply

Work

Sleep

Daily Routine

None

What have you done to obtain relief ?

Has there been a medical diagnosis ?

Yes

What is the diagnosis offered ?

Have you been hospitalised with this ?

Yes

When, and at which hospital ?

Are you currently under the care of a GP for this condition?

Yes

GP. Name

Prefix First Last

Doctors Phone

Are you taking any medication ?

Yes

If yes, please list which medications.

Have you had any surgery ?

Yes

If yes, what and when ?

Have you broken bones?

Yes

If yes, which and when ?

If you have ever been involved in a vehicular or other traumatic accident

Please describe the direction and type of impact and when the accident occurred.

Please indicate which of the following, if any, apply to you:

Allergies

Arthritis

Blood Clots

Diabetes

Dizziness

Headache

Heart Problems

High Blood Pressure

Joint Disease

Low Blood Pressure

Open lesions

Pregnant / Post Natal

Spinal Problems

Skin Problems

Varicose Veins

Other

Please specify

Do you exercise or play sport?

If yes, how and how often?

Do you wear contact lenses ?

Yes

Do you wear dentures or braces ?

Yes

Do you feel that you eat a balanced diet ?

Yes

Rate your consumption of Alcohol

Rate your consumption of Sugar

Rate your consumption of Caffeine

Rate your consumption of Tobacco

Please describe your stress level

Do you wear orthotic inserts ?

Yes

If yes, for how long?

Name any area you do NOT want treated

Contact

Call me on 086 3933 537

Address
30 Milltown Rd,
Archerstown, Ashbourne,
Co. Meath, A84 RP22, Ireland

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