Lumbo-Pelvic (Lower Back) Injury Form Fill in this form if you are suffering from Lower back pain or Lumbo-pelvic pain. Lower Back, Buttock or Abdomen Injury Form Step 1 of 5 20% Package* Initial Video Consultation Total $ 0.00 BASIC INFOName* First Name Surname Email* Enter Email Confirm Email Mobile Phone*e.g. +61_ _ _- _ _ _ - _ _ _ Date of Birth* DD slash MM slash YYYY Nationality* Which country do you live in?*Select CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweStreet Address Suburb* State*Select StateAshmore and Cartier IslandsAustralian Antarctic TerritoryAustralian Capital TerritoryChristmas IslandCocos (Keeling) IslandsCoral Sea IslandsHeard Island and McDonald IslandsJervis Bay TerritoryNew South WalesNorfolk IslandNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaPost Code* Height Weight Do you have a preference on which physiotherapist you would like?* Samuel Ward Bernie Chau Steph Alberts No Preference THE MAIN PROBLEMWhere is the location of the pain?* Lower back Bottom Abdomen Post an image of you pointing to the area of pain.Accepted file types: jpg, jpeg, png, gif.While dressed point to the area of pain. This is not mandatory. Just be extra specific below if you don't. Describe in more detail the location of the pain.*Describe the type of pain.*E.g. dull, achy, pulling, sharpWhat do you think caused the injury?*Note: If you have had previous episodes of this pain you will have an opportunity to tell us about that later in the form. Just tell us about your current pain here.How long have you had the current pain/injury for?* Is the pain constant or does it come and go?*ConstantCome and goOtherHas the pain changed since it started?*The sameBetterWorseOtherIf worse or other, describe.*INTENSITY OF THE PAINOn a Good Day, Paint out of 10?*012345678910On a bad day, Pain out of 10?*012345678910Do you get any pins and needles or numbness in your lowerback or legs?* Yes No If yes, describe.*Have you noticed a weakness in your lowerback or legs* Yes No If yes, describe.*Have you noticed any changes to your bladder or bowel activity or had any numbness through your crutch?* Yes No If yes, describe.*What increases or causes the pain in your lower back, buttock or abdomen? Tick if applicable* Sitting Bending over Picking up things from the floor Getting dressed Twisting Driving Lifting weights Rolling over in bed Putting on your shoes Looking over your shoulder Moving from being seated to standing Walking Coughing Getting in/out of the car Standing on one leg Lying on your stomach Lifting Computer use Other If other, describe.*Easing FactorsDoes anything reduce your pain? Stretches Lying on your back Massage Gentle Movement Heat Pack Nothing so far Other If other, describe.* 24 HOUR BEHAVIOURDo you have trouble sleeping at night because of the pain?* Yes No If yes, describe.*How does the pain feel in the morning?*Does the pain change throughout the days?* Yes No E.g. stiff in the morning, improves over the day or sore at the end of the day.If yes, describe.*Previous HistoryHave you had this pain before?* Yes No If yes, describe.*How long ago was it? What treatment did you have? How long did it take to recover?Have you tried any other treatments for your current pain?* Yes No If yes, describe.*InvestigationsHave you had any investigations on your lower back, buttock or abdomen?* Yes No E.g. XRAYS, MRI, CT SCANS or any other TESTS? You will be able to attach any documents later.If yes, list.* General HealthHow is your general health?* Good Ok Poor Other If other, describe your health in one word.* Any medical conditions?* Yes No If yes, list.*Have you had any unexplained weightloss, loss of appetite or history of steroid use? Yes No If yes, describe.*Have you had any night sweats?* Yes No If yes, describe.*Do you take any regular medications?* Yes No If yes, list.*Have you taken any medications for this problem?* Yes No If yes, list.*Lifestyle FactorsWhat do you do for work?* Has this injury affected your work?* Yes No If yes, how.*How often do you exercise? I don't exercise 1-2 times per week. 3-5 times per week 7 times per week Other If other, how often do you exercise and what do you do?*What type of exercise do you do?*Has this injury affected your exercise or hobbies?* Yes No If yes, describe.*ADDITIONAL INFORMATIONIf you have anything else to add please mention it hereAttach any documents that you may feel are relevant here.Max. file size: 8 MB. Please read our terms... Terms & Conditions and Privacy Policy Note* I have read and agree to the Terms & Conditions and Privacy Policy
