Aristos Physiotherapy

Pre-Consultation Intake / Consent Form

Thank you for choosing Aristos Physiotherapy to help guide you with your recovery from injury / pain. Please read the information below carefully and complete the Intake and Consent Form at the bottom of the page prior to your appointment.

If you have any questions please contact our Lead Physiotherapist Ryan – ryan@aristosfitness.co.uk. For more information about what to expect in terms of our Aristos Physiotherapy processes during your Initial or Return Consultation please click here.

Aristos Physiotherapy Intake and Consent Form

Prior to attending your consultation, please complete the Intake and Consent Form below and allow us to help you get back to doing what you love.

Name

First Name

Last Name

Email

Phone Number

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please tell us a short story about what you are looking for help with.

What is your pain stopping you from doing and how is it making you feel?

Please be as specific as possible, what movements from your everyday life are uncomfortable?

Is there anything you would like to get back to, but feel that you can’t because of your pain?

How long has this been going on for?

Do you have any other Past Medical History e.g. allergies or underlying conditions?

Have you had any injuries in the past? (no matter how long ago or small, for example sprained ankles, broken bones, ligament injuries, fractures etc).

Please give details no matter how long ago or or how insignificant it may seem; for example sprained ankles, broken bones, ligament injuries, fractures etc.

Please detail some information about your current sleep – How do you currently sleep, how do you feel in the morning? Do you wake during the night?

Stress – Please rate your current stress levels on scale of 0-10. 0 being not stressed at all, and 10 being very stressed. If able, please given an indication as to what may be contributing to your stress levels?

How did you hear about us?

If through word of mouth, please can you tell us who let you know about us so we can thank them.

Please tick this box to notify us that you give consent to undertake your consultation and that you have read and agree to our Aristos Terms and Conditions.

I consent to undertake a consultation and to the Aristos Fitness Terms and Conditions.

Aristos Physiotherapy

Pre-Consultation Intake / Consent Form

Aristos Physiotherapy Intake and Consent Form

please click here for a copy of our Aristos Fitness Terms and Conditions

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