General Client Details
Details of Health Professional:
Are you currently experiencing OR ever been diagnosed with any of the following conditions?
Please note the AGE of each of your other children. Please also note the mode of delivery (vaginal or section) for each child, the weight at birth of each child, and report any previous obstetric injuries (tear/episiotomy) or any complications related to each delivery and pregnancy.
Please describe where your pain complaints are. Be as accurate as possible, noting down whether the pain is sharp and shooting or dull, achy and muscular in nature. When did the pain start?
Outline easing factors such as rest, ice, heat, certain positions, other therapies etc. Anything that has helped.
Are you best in the morning? Worst in the morning? Do things settle down with movement or get worse with movement? Please be as accurate as possible.
Current Health Status
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We really appreciate the time that you put in to completing this form. The information provided will very much help your clinican during your initial consultation.
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