Thoracic/Chest Injury Form Fill in this form if you are suffering from thoracic/chest pain. Mid Back/Chest Injury Form Step 1 of 5 20% Package*Initial Video ConsultationTotal $ 0.00 BASIC INFOName* 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?*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*HeightWeightDo you have a preference on which physiotherapist you would like?* Samuel Ward Bernie Chau Steph Alberts No preference THE MAIN PROBLEMWhere is your pain?* Mid back Chest Other 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 exact location of the pain?*What do you think started the pain?*How long have you had this current pain?*You will have an opportunity to mention previous episodes of the same pain later on.Is it constant or does it come and go?*ConstantCome and goOtherIf other, describe.*Has the pain changed since it started?*The sameBetterWorseOtherIf other, describe.*If worse, describe.*INTENSITY OF THE PAINOn a Good Day, Paint out of 10?*012345678910On a bad day, Pain out of 10?*012345678910How may pillows do you sleep with?*OneMore than OneAny pins and needles or numbness in your arms?*YesNoIf yes, describe.*What movements cause you pain?* Cough Sitting Computer use Smartphone use Deep breathing Sneezing Reading Reaching behind you Reaching up Lying on your side Hanging clothes on the line Twisting to the side Other Tick if applicable.If other, list.*Easing FactorsDoes anything reduce your pain? Stretches Heat Pack Massage Gentle movement Ice Pack Other If other, list/describe.* 24 HOUR BEHAVIOURDo you have trouble sleeping at night because of the pain?*YesNoIf yes, describe.*Does the pain change throughout the day?*YesNoE.g. stiff in the morning, improves over the day, sore at the end of the day.If yes, describe.*If no, describe.*Previous HistoryHave you had this pain before?*YesNoIf yes, describe.*How long ago was it? What treatment did you have? How long did it take?InvestigationsHave you had any investigations on your shoulder/upper arm?*YesNoE.g. XRAYS, MRI, CT SCANS or any other TESTS? (You will have an opportunity to attach these later on)If yes, describe.* General HealthHow would you describe your general health?* Good Ok Poor Other If other, use one word to describe.*Any current medical conditions?* Yes No If yes, describe.*Have you had any unexplained weightloss, loss of appetite or history of steroid use?*YesNoIf yes, specify.*Have you had any night sweats?*YesNoIf yes, describe.*Do you take any regular medications?*YesNoIf yes, describe.*Have you taken any medications for this problem?*YesNoIf yes, describe.*Lifestyle FactorsWhat is you occupation?*What is involved physically?Has this injury affected your work?*YesNoIf 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 If other, describe how often and type of exercise you do.*What type of exercise do you do?*Has this Injury affected your exercise or hobbies?*YesNoIf yes, describe.*ADDITIONAL INFORMATIONIf you have anything else to add please mention it here.Attach any documents that you may feel are relevant here. 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