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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*
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.
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.
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.
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

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