Archives: Quizzes & Surveys

Injections Consent

Injection Consent form to be filled out prior to attending treatment at Meyer & Associates.

Patient First and Last Name
Patient Email Address
Telephone Number

Patient Information

Patient Information form to be filled out prior to your first appointment at Meyer & Associates.

Title (Mr, Mrs, Miss, Dr, etc.)
Patient First and Last Name
Patient Email Address
Telephone Number

Covid19 Declaration

Please read the following carefully and confirm that you are happy to proceed with treatment:
Due to the Coronavirus pandemic, we are required to take to take extra precautions when seeing patients face-to-face. 
It is important to understand that there is a risk of infection, when attending Physiotherapy treatment.
Do not attend if you or your family presented with COVID-19 symptoms in the last 7 days:
  • Chronic dry cough,
  • Increased temperature or fever
  • Loss of smell/taste.
PROTOCOL WHEN ATTENDING APPOINTMENTS:
  1. Use the allocated undercover Regus parking (particularly if it is raining) or use the visitors parking provided in front of the main Regus entrance. 
  2. Parking is free of charge BUT AVOID PARKING PENALTIES by register your vehicle registration at the main reception.  
  3. Please enter main reception and observe 2 meter social distancing. 
  4. Aim not to touch reception furniture or use the restrooms.
  5. Your physiotherapist will meet you and supply you with hand sanitiser and measure your body temperature.
  6. Please wear a mask and cover your NOSE and MOUTH. 
  7. Do not wear any gloves - you will be asked to remove this on first contact with us. Inform your physiotherapist if you have any allergies to latex or powder, prior to the appointment. 
  8. Only the patient that is receiving treatment on the day, will be allowed into the clinic.
  9. If the patient requires a chaperone, let us know, prior to the appointment.
  10. Do not bring any unnecessary belongings including handbags/sunglasses etc. 
  11. Kindly note that we are not accepting any paper documentation in the clinic at present. 
  12. The treatment duration is 30-45min.
  13. Just before leaving the clinic you will be required use hand sanitiser again. Keep your mask on UNTIL you can wash your hands with soap and water. Try not to touch your face. 
  14. Methods of payment: ONLY Cards are currently accepted.
  15. Consider remote consultations if you think that the problem can be resolved in that manner.
  16. Remember we have to work together to make sure that everybody stay safe, so please apply the rules.  

Patient First Name

Patient Last Name

Patient Date of Birth

Telephone Number (Parent number if patient is under 18)
Email Address (Parent address if patient is under 18)

UNIVERSITY OF BATH: Shoulder Research project – SURVEY

If you are a Tennis Player and would like to participate in our Shoulder Study, please fill in the Questionnaire below and we will contact you with further details.

The Questionnaire should take no longer than 10 minutes to complete.

Name and Surname Email Phone Number

To prevent robots from filling this form, please retype the letters you see in the image above.
1. 

Gender

2. 

Date of Birth (dd/mm/yyyy)

3. 

Age in Years

4. 

Preferred location

5. 

Current Level of Competition


6. 

How many hours of tennis do you play per week? (Including on-court training and matches)

7. 

Years of Playing Tennis

8. 

Which is your Dominant Hand?

9. 

Type of Serve used most frequently

10. 

Do you have any Shoulder Pain?

11. 

Which side is the pain?

12. 

How much is you Pain Score on a Scale of 0 (no pain) to 10 (extreme pain)?

13. 

When did the pain start?

14. 

Do you have Pain at Night?


15. 

Can you Serve with your pain?


16. 

Did you consult any of these professionals about your shoulder pain?


17. 

If you have seen someone, what was their Diagnosis?

18. 

Have you had any Imaging (X-Rays/ Ultra-sound/ MRI) scans taken of your shoulder?

19. 

Do you suffer from Cervical Pain?

20. 

Do you suffer from Frozen Shoulder?

21. 

Do you suffer from Diabetes?

22. 

Have you had any Shoulder Surgery in the last 12 months?

23. 

Have you had any Shoulder Infiltrations?