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Thigh/Upper Leg Injury Form

Fill in this form if you are suffering from thigh/upper leg pain. (Hamstring, quadriceps or groin).

Thigh/Upper Leg Injury Form

Step 1 of 5

20%

Package*
- Initial Video Consultation
Total
$ 0.00

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BASIC INFO
Name*
First Name Surname
Email*
Enter Email Confirm Email
Mobile Phone*
e.g. +61_ _ _- _ _ _ - _ _ _
Date of Birth*
Date Format: DD slash MM slash YYYY
Nationality*
Which country do you live in?*
Street Address
Suburb
State
Post Code
Height
Weight
Do you have a preference on which physiotherapist you would like?*
- Samuel Ward
- Bernie Chau
- Steph Alberts
- No Preference

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THE MAIN PROBLEM
Which leg is in pain?*
Post an image of you pointing to the area of pain.
While dressed point to the area of pain. This is not mandatory. Just be extra specific below if you don't.
Where is the location of the pain in your thigh/upper leg?*
What do you think caused the pain?*
How long have you had this current pain?*
You will have an opportunity to discuss previous episodes of this pain later on. Focus on the current episode of pain.
Is it constant or does it come and go?*
If other, describe.*
Has the pain changed since it started?*
If other, describe.*
If worse, describe.*
INTENSITY OF THE PAIN
On a good day, pain out of 10?*
On a bad day, pain out of 10?*
AGGRAVATING FACTORS
What increases of causes the pain in your thigh/upper leg?*
- Walking
- Running
- Sitting
- Sitting with your legs crossed
- 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 FACTORS
Does anything reduce your pain?*
- Stretches
- Lying on your back
- Gentle movement
- Heat Pack
- Other
If other, describe.*

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24 HOUR BEHAVIOUR
Do you have trouble sleeping at night because of the pain?*
- Yes
- No
If yes, describe.*
Does the pain change throughout the days?*
- Yes
- No
E.g. stiff in the morning, improves over the day, sore at the end of the day.
If yes, describe.*
If no, describe.*
Previous History
Have you had this pain before?*
- Yes
- No
If yes, describe.*
How long ago was it? What caused it? What treatment did you have? How long did it take?
Have you tried any other treatments for your current pain?*
- Yes
- No
If yes, describe.*
Investigations
Have you had any investigations on your thigh/upper leg?*
- Yes
- No
E.g. XRAYS, MRI, CT SCANS or any other TESTS? You will have an opportunity to attach any relevant documentation later on.
If yes,*

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General Health
How would you describe you general health?*
- Good
- Ok
- Poor
- Other
If other, use one word to describe.*
Any current medical conditions?*
- Yes
- No
If yes, describe.*
Any past medical conditions?*
- Yes
- No
If yes, describe.*
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, describe.*
Have you taken any medications for this problem?*
- Yes
- No
If yes, describe.*
Lifestyle Factors
What is your occupation?*
What is involved physically?
Has this injury affected your work?*
- Yes
- No
If yes, describe.*
How often do you exercise?*
- I don't exercise regularly.
- 1-2 times per week
- 3-5 times per week
- 7 times per week
- Other
Pre Injury
If other, how often do you exercise and what type.*
What type of exercise do you do?*
Has this injury affected your exercise or hobbies?*
- Yes
- No
If yes, describe.*
ADDITIONAL INFORMATION
If you have anything else to add please mention it here.
Attach any documents that you may feel are relevant here.
Please read our terms...
Terms & Conditions and Privacy Policy
Note*
- I have read and agree to the Terms & Conditions and Privacy Policy

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