HCI Pre Treatment Questionnaire

This questionnaire is designed to help speed up the subjective part of your assessment and therefore increase available time for objective observations and any treatment. The information given will assist your therapist in better understanding your condition and if there is any root cause of it, it will direct their objective examination of you, help to understand what you are hoping to achieve from physiotherapy and guide any treatment you need.

This form should take your approximately 10 minutes to complete.

Question Title

* 1. Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough,
sore throat, respiratory illness, difficulty breathing)?

Yes

No

Other (please specify)

Question Title

* 2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last
14 days?

Yes

No

Other (please specify)

Question Title

* 3. Is there a loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal?

Yes

No

Other (please specify)

Question Title

* 4. Do you think you have caught COVID-19?

Yes

No

Question Title

* 1. Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough,sore throat, respiratory illness, difficulty breathing)?

Question Title

* 2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last14 days?

Question Title

* 3. Is there a loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal?

Question Title

* 4. Do you think you have caught COVID-19?

* 1. Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough,
sore throat, respiratory illness, difficulty breathing)?

* 2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last
14 days?