Assessment Form

Please fill out the following form. Once it is submitted a physiotherapist will be in touch to schedule your video consultation.

This consultation will be done via a program called Physiapp. Through Physiapp you will also receive your tailored exercise program via narrated videos and have access to your physio through an in-app message service.
PhysiApp is completely free to download from the App store and Google Play store or can be accessed via your browser. Built-in reminders help you to stay on track towards a better you!

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online physiotherapy assessment form

* Indicates required field

Name *

First

Last

DOB *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

pain & injury

Are you currently suffering from any musculoskeletal pain or injury? *

Yes No

If yes, please provide details *

If you answered yes to the question above, are you currently undertaking any specific treatment for it? *

Yes No

If yes, please provide details *

Have you had any previous musculoskeletal injuries or pain? *

Yes No

If yes, please provide details and dates *

health

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes No

Do you feel pain or tightness in your chest when you do physical activity? *

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness or faint? *

Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes No

Is your doctor currently prescribing medication for your blood pressure or a heart condition? *

Yes No

Do you know of any other reason why you should not do physical activity? *

Yes No

Are you suffering from any other current health conditions? *

Yes No

If yes, please provide details *

Do you have a past history of any significant health conditions? *

Are you currently taking any medications or supplements? If so, please list them. *

social history

Occupation *

Apart from riding, do you currently do any other physical activity/exercise? *

Yes No

If yes, what do you do? *

How would you rate your general activity level? *

riding

What kind of riding do you do? *

Current Level? *

Number of rides per week? *

Do you experience any pain while riding? *

Yes No

Do you feel or does anyone comment that you are crooked in the saddle? *

Yes No

During general riding or competition, do you ever suffer from breathlessness? *

Yes No

In general, how would you rate the intensity of your riding sessions? *

If you would like us to review any photos or footage of yourself riding, please upload them below.

Photo/video upload *

Max file size: 20MB

Photo/video upload *

Max file size: 20MB

Photo/video upload *

Max file size: 20MB

athletic wellness & performance

Based on how you feel today, how would you rate yourself in the following areas?

Fatigue *

Sleep quality *

Stress levels *

General muscle soreness *

Please comment below to elaborate on any of the above, especially if you feel that today is different to how you've felt on average in the past month. *

Overall, how satisfied are you with your current level of athletic performance? *

How many hours of sleep do you get per night on average? *

Do you have any rest days per week riding or other physical activity? *

Yes No

If yes, how many per week? *

nutrition & hydration

How many cups of water do you drink before, during and after riding or other exercise? *

How many cups of water do you drink on an average day? *

Are you following a special diet (eg vegetarian, high protein, allergies)? *

Do you regularly skip meals? *

Yes No

Please describe your average daily diet *

Do you currently take any vitamins or dietary supplements? *

Yes No

If yes, please provide details *

Do you know much about nutrition in relation to performance and recovery? *

recovery

How well do you feel that your body feels following a regular riding session? *

How well do you feel that your body feels following a competition? *

Do you follow a regular recovery program for yourself post competition? *

Yes No

If yes, what do you do? *

Submit

online physiotherapy assessment form

pain & injury

health

social history

riding

athletic wellness & performance

nutrition & hydration

recovery

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