Consultation Form Medical Consultation Form Patient information Name Last name Email Contact Phone Birthdate Gender Man Woman You are pregnant? Yes No Work/Occupation Activity Level Sedentary: Very little or no physical activity. Moderate: I practice sports between 2 and 4 days a week. High: I train 5 or more times a week. Professional or Semi-Professional: I train more than 5 days a week with a high level of commitment. Type of physical activity Reason for the consultation In which area do you feel pain or discomfort? Head (dizziness, vertigo) Neck Shoulder Elbow Forearm Hand Fingers of the hand Tingling in the hand Dorsal column Chest Ribs Belly Pubis Lumbar Sacrum Coccyx Hip Knees quadriceps area Lateral aspect of the thigh Rear thigh area Leg Ankles Feet Toes Have you suffered a traffic accident or any major trauma that is related to your problem? Yes No Do you know the cause of your problem or do you relate it to something? How would you describe the intensity of the pain on a scale from 1 - no pain - to 10 - disabling pain? 1 2 3 4 5 6 7 8 9 10 Since when do you feel pain or discomfort? Between 1 and 3 weeks Between 1 and 2 months Between 3 months and a year More than 1 year Do you feel pain in other areas? Is there any more detail about your pain or discomfort that you would like to tell us? Do you have a medical diagnosis? Which? Are you going to provide medical test information? Yes No Send your medical tests before the appointment: Email address manuelcuencafisioterapia@gmail.com Subject: Medical proof + your name.Includes: Medical proof + accompanying report. Have you been treated before? What type of treatment have you received? Clinical data Do you have any allergies? What kind? Do you have any illness? Which one? Do you take any medication? Which one? Do you use any of these items? Orthosis Prosthesis Insoles Splint Glasses Do you have a fear of needles? Yes No ...we are already finishing What do you expect from your treatment? Personal data protection I have read and accept the privacy policy. Responsible for data processing: Manuel Cuenca Fisioterapia & Osteopathy. Purposes and legitimacy of the treatment: Sending communications of services with the consent of the interested party. Conservation of data: No longer than necessary to maintain the purpose of the treatment. Communication of data: Data will not be communicated to third parties, except under legal obligation. Rights that assist the User: Right to withdraw consent, access, rectification, portability and deletion of their data, and limitation or opposition to their processing. Contact information to exercise your rights: Email: info@manuelcuencafisioterapia.com. You can consult additional information about our data protection policy here:Polí ;Privacy ethics. Send
