Re-Exam - Physio

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Last Name *

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RE-EXAM - PHYSIO

Do you have any questions regarding your care?:

Yes
No

If you answered yes, please describe::

To what degree have your treatment goals at Bounce Physio been achieved? (0 = not at all, 10 = completely achieved):

What conditions have improved with treatment?:

Neck / Headaches
Shoulder / Upper Arm
Elbow / Forearm
Wrist / Hand
Hip / Thigh / Buttock
Knee /Lower Leg
Foot & ankle
Balance
General conditioning
Womens Health
None

Other::

What aspects have improved?:

Pain
Movement
Strength
Function
Balance

Other::

What conditions are still bothering you?:

Back
Neck / Headaches
Shoulder / Upper Arm
Elbow / Forearm
Wrist / Hand
Hip / Thigh / Buttock
Knee /Lower Leg
Foot & ankle
Balance
General conditioning
Womens Health
None

Other::

What aspects are affecting you?:

Pain
Movement
Strength
Function
Balance

Other::

HEALTH GOALS

What are your health goals at present?:

Pain relief (patch up or symptom only repair)
Rehabilitation (patch up & restore)
Preventative health care (better long term health outcomes)

Other::

Do you feel you would benefit from further treatment at present?:

Yes
No
Unsure

If you answered yes (above), how often do you feel would suit you best?:

A couple of times a week
Weekly
Fortnightly
Monthly
6 weekly
In 3 months or more
Not sure

EXPERIENCE

Please rate the degree of care, concern and attention you feel you have received from us during treatment. (0=none at all 10=excellent):

Is there someone you know who might benefit from Physio at present?:

Yes (#rry)
No (#rrn)

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