Full Name Address Post Code Your Email GP Name Date of Birth Sex MaleFemale Occupation Phone Number GP Surgery Please describe your current problem and symptoms below: How long have you had your current problem? Less than 2 weeks2-6 weeks7-12 weeksmore than 12 weeks Is your problem getting? WorseBetterNot Changing If in pain, how would you describe it? NoneMildModerateSevere Is your pain constant (present all the time)? N/AYesNo Is your pain disturbing your sleep? NoYes, difficulty getting to sleepYes, woken up from sleepYes, unable to sleep at all Are you off work because of this problem? YesNo If yes, how long? Are you taking medication? YesNo If yes, what are you taking? Have you had this problem before? YesNo If yes, how long ago? If yes, have you had any other therapy for this problem? YesNo If yes, what treatment did you receive? On agreeing to this form, you consent to be treated via Telehealth and understand that certain communications will be required as part of the treatment.You may decline any of the treatment or communications that you have been offered.
