Health Programmes

Name (mandatory)

Email Address (mandatory)

Phone Number (mandatory)

What is your age? What is your age? Less than 13 13 - 18 19 - 25 26 - 35 36 - 50 Over 50 Prefer not to say

Which area of your body have you injured? Which area of your body have you injured? Lower Back Neck Shoulder Hip Knee Ankle Elbow Wrist Tension Headache

How did it start?

How long ago did you injure yourself? How long ago did you injure yourself? Less than 4 weeks ago Between 4 weeks and 3 months Between 3 and 12 months Longer than 12 months ago 12 months or more

Are you... Are you... Getting better Getting worse Staying the same

Have you been examined by a medical professional? Have you been examined by a medical professional? Yes No

If yes, what was your diagnosis?

If yes, what advice/treatment were you given?

Has it helped? Has it helped? Yes No

Did you follow the advice or treatment plan? Did you follow the advice or treatment plan? Yes No

If not, why?