Pre-Screening Questionnaire

Please indicate the condition you are attending for (tick the appropriate response) :
Please describe the diagnosis of your condition (if known):
 
 
 
 
 
 
 
 
 
 
 
 
What treatment above has been the most successful and who was your treating practitioner?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If No then please provide further information:
Please provide ProActive Rehabilitation and Health with any other information that is necessary for the successful rehabilitation of your injury / condition:
By entering my name in the Electronic Signature box, I declare that the above information is correct and I understand that it will remain confidential except for the exchange of necessary information between instructors who may teach me