Monday to Friday: 7.30 AM – 8 PM Saturday: 8 AM – 3 PM Sunday: Closed Address: 150 Tulip Street Sandringham VIC 3191 Email: physio@sportsphysio.com.au Fax: 03 9034 5256 CONTACT FORM

Your Name

Your Email

Your Phone Number

Your Message

MAP

TELEHEALTH SCREENING FORM

Please only complete this form if you wish to arrange your Telehealth booking. If you prefer an inhouse consultation, please contact our clinic on 03 9880 2337.

For detailed information about the telehealth service Click Here.

Your Name

Your Email

Your Phone Number

Your Full Address

Preferred Contact Method
PhoneEmail

Reason for your booking e.g. what are your ailments and how did this occur?

Has this happened before? If so, please provide details

How would you describe your symptoms, and where they are felt?

If you have pain, can you rate it out of 10 (10 being maximum):
12345678910

Is your pain constant or intermittent?

Do you have any pins and needles or numbness anywhere? If yes, please provide details

What aggravates your symptoms e.g. movements, postures, activities?

What eases your symptoms eg movements, exercises, positions, medications, treatment?

How are your symptoms first thing in the morning?

Do your symptoms change as the day progresses? Please describe

How are your symptoms at the end of the day?

Do your symptoms wake you at night?

What exercise are you doing at present? Please include frequency

What is your occupation and what are the physical demands of your job?

How would you describe your general health?

Do you have any medical conditions? If so, please describe

Have you had any major surgery in the past? Please describe

Do you regularly take medication? If so, please describe

Have you had any scans or tests done recently or in the past for your current condition?

Have you had any recent, unexplained weight loss?

Have you taken steroids or steroid based medication in the past? If yes, please provide details

Are you pregnant?

Do you suffer dizziness? If yes, what aggravates and eases your dizziness?

Do you suffer headaches? If yes, is this recent since your current condition?

If you normally experience headaches, are your current headaches different in any way to your usual headache? Please provide details

Do you have a pacemaker?

Has your bladder or bowel function changed since your current condition?

Have you lost any sensation in that area recently?

Have you been losing balance or feeling unsteady when you walk recently?

Have you lost sensation in both hands or both feet recently?

What are you looking to get out of the Telehealth session?

Do you have any other relevant information or comments you would like to make?

HOME VISIT SCREENING FORM

Please only complete this form if you wish to arrange your Home Visit booking or please contact our clinic on 03 9880 2337.

Your Name

Your Email

Your Phone Number

Your Full Address

Preferred Contact Method
PhoneEmail

Reason for your booking e.g. what are your ailments and how did this occur?

Has this happened before? If so, please provide details

How would you describe your symptoms, and where they are felt?

If you have pain, can you rate it out of 10 (10 being maximum):
12345678910

Is your pain constant or intermittent?

Do you have any pins and needles or numbness anywhere? If yes, please provide details

What aggravates your symptoms e.g. movements, postures, activities?

What eases your symptoms eg movements, exercises, positions, medications, treatment?

How are your symptoms first thing in the morning?

Do your symptoms change as the day progresses? Please describe

How are your symptoms at the end of the day?

Do your symptoms wake you at night?

What exercise are you doing at present? Please include frequency

What is your occupation and what are the physical demands of your job?

How would you describe your general health?

Do you have any medical conditions? If so, please describe

Have you had any major surgery in the past? Please describe

Do you regularly take medication? If so, please describe

Have you had any scans or tests done recently or in the past for your current condition?

Have you had any recent, unexplained weight loss?

Have you taken steroids or steroid based medication in the past? If yes, please provide details

Are you pregnant?

Do you suffer dizziness? If yes, what aggravates and eases your dizziness?

Do you suffer headaches? If yes, is this recent since your current condition?

If you normally experience headaches, are your current headaches different in any way to your usual headache? Please provide details

Do you have a pacemaker?

Has your bladder or bowel function changed since your current condition?

Have you lost any sensation in that area recently?

Have you been losing balance or feeling unsteady when you walk recently?

Have you lost sensation in both hands or both feet recently?

What are you looking to get out of your home visit?

Do you have any other relevant information or comments you would like to make?

Do you have a room/space in your house to set up a portable table?

Is there nearby parking outside?

Agreement
In order to provide a home visit we required another person to be present in your home during the home visit.

After sending this message, a member of the team will contact you shortly to organise the home visit as well as payment beforehand.

Location Map

Our Commitment to Safety & Hygiene

In the health interest of our patients and staff at Sandringham Sports Physio we request that if you are feeling unwell or experiencing cold/flu-like symptoms inclusive of:

Fever
Cough
Sore Throat
Lethargy / fatigue
Shortness of breath

Please refrain from attending our clinic until you are clear of symptoms. Please contact one of our friendly Reception staff so we can reschedule your appointment. Thank you for your consideration.

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