New Client Intake — Joel Dimech Physiotherapy

This takes about 10 minutes. Answer as thoroughly as you can — it's the foundation for your first assessment and lets us make the most of the time we have together.

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Personal & contact

Full Name *

Date of Birth *

Mobile Number *

Email Address *

Occupation (optional)

Emergency Contact — Name *

Emergency Contact — Phone *

Emergency Contact — Relationship (optional)

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Sport & training background

Primary Discipline

What do you train, and where? (optional)

Current Training Frequency (optional)

Competition Level (optional)

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Current complaint

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Injury & medical history

List all injuries you remember, even ones you think are irrelevant (e.g. concussion, fractures, ligament tears, asthma, vision or balance issues) *

Past surgeries (optional)

Current medications (optional)

Relevant medical conditions (optional)

Allergies (optional)

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Health screening

Standard pre-activity screening. Answer honestly — a 'yes' doesn't stop us from working together, it just changes how we start.

A doctor has told me I have a heart conditionI feel pain in my chest during physical activity or at restI have lost my balance due to dizziness, or lost consciousness, in the last 12 monthsI have a bone or joint problem that could be made worse by exerciseA doctor is currently prescribing me medication for blood pressure or a heart conditionI have had unexplained weight loss recentlyI have pain at night that doesn't ease with restI have numbness or weakness that is progressively getting worseI have experienced loss of bowel or bladder control

If you checked any of the above, give a few more details (optional)

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Goals & expectations

What are you expecting from the session? (optional)

What are your goals? *

How committed are you to spending 10 minutes a day on home rehab? (0–10)

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Consent

I have read and agree to the Client–Practitioner Contract.I understand active rehab includes loading, exercise, and movement testing, and I consent to participate. I understand physiotherapy is not a substitute for medical diagnosis or emergency care.

Type your full legal name as your signature *