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St Brendan’s Physiotherapy · Form PA-3

Before your first appointment

Write numbers one digit per box. Mark one oval in each row. It takes about four minutes.

Date of birth

1About your visit

2Over the past week 0 never · 3 every day

1Pain wakes me at night
2I climb a flight of stairs without stopping
3I can kneel and get up again
4Pain stops me doing my job or chores
5I take pain relief for thisBlank — needed before your appointment
6The knee gives way under me
7It is swollen by the end of the day
8I have stopped a sport or hobby because of it