Assessment Form

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

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? *

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?

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

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? *

online physiotherapy assessment form

pain & injury

health

social history

riding

athletic wellness & performance

nutrition & hydration

recovery