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First Name*
Last Name*
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Phone Number*
Altername Number
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Date Of Birth*

Health Details:-

About your problem:-

Please give brief description of your problem. Give details of how it started, for example, injury just came on or long term problem*
How long have you had this problem?*

Previous history:-

Please mention if you have any known medical history e.g. Diabetes/ High or low blood pressure/ cardiac problems/any other known problem. )
If yes please describe (Since when you are suffering from the illness? Are you on any medications for the same? Is your illness under control or any secondary complications exist?

For female patients:-

Please mention if you are pregnant or lactating

Your symptoms:-

Do you have any pain? Please give details
Describe the nature of pain: Dull pain/ shooting pain/ burning pain/ constant nagging pain/ just niggles/ more of discomfort than pain
Does your pain increase with any particular movement?
Does your pain reduce with any particular movement?
Is this problem getting worse?
Are you off work because of this problem?

Tingling or numbness:-

Do you have any pins and needles?
Do you have any numbness?

Functional difficulty:-

If you are at work, are you restricted in your work duties because of this problem?
Is performing tasks of daily life restricted due to pain?
If you have any x -rays/ M.R.I/ Blood reports/ Ultra sonography reports /other health professional's referral note in relation to the area of consultation
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I agree terms and condition

Terms & Conditions

I give my consent to participate in online physiotherapy rehabilitation exercise program for joint care conducted by Cura physiotherapy Clinic.

Participation in physical activity has shown to produce many benefits, both physically and mentally. They include improved endurance, increased muscle strength, flexibility as well as decreased stress level.

I recognize that exercises can cause some injuries to musculoskeletal system (sprains, strains, etc.) and to cardiovascular system (like dizziness, discomfort in breathing, etc.). I hereby certify that I know no medical problem past or present except those mentioned in admission form that would increase my risk of illness and injury as a result of participation in regular exercise program.

Testing and evaluation
I agree to inform my therapist if my details or medical conditions change during my exercise program schedule. I understand that not providing such information can be detrimental to my health and safety. By signing this consent form I understand that I am personally responsible for my action and I waive off my therapist of any responsibility should I incur any injury during the program.