Follow the steps to fill out the form online with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in the designated editor for completion.
2. Begin by entering your full name in the provided field at the top of the form.
3. Next, indicate your date of birth in the specified section to help verify your identity.
4. Fill in the date on which you are completing the form.
5. In the first question, clearly describe your major problem that you are seeking treatment for today.
6. Utilize the diagram provided on the form to indicate where you feel your problem is located.
7. For the pain description, circle whether your pain is constant or intermittent.
8. Circle a number on the pain scale that corresponds with the intensity of your pain, ranging from 0 (no pain) to 10 (very sharp pain).
9. Circle an option to describe how you would characterize your pain — options include sharp, stabbing, dull ache, or other.
10. Next, indicate whether you have experienced any additional symptoms by circling each applicable option.
11. Detail how long you have experienced the problem in the appropriate space.
12. If applicable, describe any injury or accident that caused the problem in the designated area.
13. Circle how the problem has been progressing since it began: about the same, getting better, or getting worse.
14. Inquire about past occurrences of similar problems and document them in the provided section.
15. Answer whether this problem affects your sleep by providing your response in the given space.
16. Specify any movements, activities, or positions that exacerbate your problem in the appropriate area.
17. Similarly, note any movements or activities that improve your condition.
18. List any other professionals you have consulted regarding this problem.
19. Document any sporting activities you are currently participating in.
20. If applicable, include any exercises you are doing to alleviate the problem.
21. Mention any other illnesses, allergies, or health issues you have in the appropriate section.
22. Indicate any medications you are currently taking.
23. Lastly, provide information about any X-rays or scans related to your problem.
24. After completing the form, ensure to sign where indicated for both the patient and physiotherapist.

Complete your Confidential Patient History Form online to help us assist you effectively.