Questionary Forms - Rehab Lab

Basic Patient Information and Presenting Pathology and Pain Symptoms:

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What is your full name?

How old are you?

What is your date of birth?

What is your gender?

What is your native language?

What is your E-mail address?

What is your phone number?

What is your fat percentage (if known)?

What is your weight?

What is your length (cm)?

What is the main issue or complaint you are seeking help for?

What diagnosis or pathology have you been given by the doctor/specialist?

How long have you been experiencing these symptoms?

Have you ever received physiotherapy treatment for these complaints before?

What is the maximum duration of time you can dedicate to training/therapy (weekly basis)?

What sports have you practiced in the past and/or are currently engaging in? Please list any sports you have practiced for at least five years or longer.

Can you identify any specific activities or moments that worsen or improve your symptoms?

Do your symptoms impact your daily life or work?

Do you smoke, and if so, how many cigarettes do you typically smoke per day?

How often do you consume alcohol in an average week, and how many drinks do you typically have during a night out?

Are there any other medical conditions we should know about?

Are you currently taking any medication relevant to your treatment?

What are your specific goals for physiotherapeutic treatment?

How do your symptoms affect your overall quality of life?

Where do you feel the most pain or discomfort?

Can you identify any specific movements or activities that trigger your symptoms?

What kind of pain do you experience? (e.g., sharp, burning, dull)

How often do you experience pain? Is it constant or does it occur during certain movements or activities?

Do your symptoms limit your mobility or daily functioning?

Have you tried any treatments or exercises for your symptoms? If so, what were the results?

Are there any activities you would like to be able to do but currently cannot due to your symptoms?

Are you aware of how your posture may affect your symptoms?

What specific goals do you have for improving your mobility, strength, or reducing pain?

What movements/actions provoke or exacerbate the pain?

Have you had surgery?

What type of surgery did you undergo?

What is the prescribed treatment by the orthopedist?

Are you allowed to bear weight?

Which movements/actions alleviate or relieve the pain?

Do you have any training equipment/facilities at home (for your personal training plan)? If yes, please specify what equipment you have available.

When is your next appointment with the doctor?

Do you have any other concerns or questions about your symptoms that you would like to discuss?

Basic Patient Information and Presenting Pathology and Pain Symptoms:

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