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Home
About
Our People
Free Balance Check
Services
Contact

Appointment with Tony Cassis

book an Online appointment-Existing patients

Book an online appointment-New patients

You are here if you have been referred to Tony Cassis. If you would like to read more about Tony, please click here

If you would like to make an appointment with Tony, feel free to call 0395987787

Tony would also like you to send him some information about yourself before you see him.

Below are links to 2 questionnaires Tony would like you to complete and submit. Your answers will provide Tony with some preliminary insight as to how best he can assist you.

The first is a “General Health Information Questionnaire”. The second is a “Nervous System Sensitivity Questionnaire”.

[expand title=”Please click here and complete and submit the two forms below. “] When you complete the first one, click the submit button, then click here again to complete the second form, and click submit again. Whew! A bit complicated, we know, but it will be worth it. Tony will reply within a few days with an opinion as to whether our clinic is suitable for your condition.

Full Name *

Date of birth (DD/MM/YYYY *

Your email address *

Phone Number (so Tony can call you)

When did your problem start *

What symptoms do you experience? *

How is your problem affecting your activities? *

Is there significant pain (try to rate out of 10) *

What other health professionals have you seen? *

When did you receive medication, surgery or therapy? *

What other health problems do you have? *

What surgeries have you had (list them all) *

What home exercise rehabilitation do you do for your problem? *

What is your general exercise level? *

Any thing else you want to add, feel free to write as much as you wish

Phone

First

Last

Date of Birth (dd/mm/yyyy)

Email *

Choose one option for each of the following questions. Answer each question as it relates to how you have been feeling in the past month

1. I feel unrefreshed when I wake up in the morning *

2. My muscles feel stiff and achy *

3. I have anxiety attacks *

4. I grind or clench my teetch *

5. I have problems with diarrhoea and/or constipation *

6. I need help in performing my daily activities *

7. I am sensitive to bright lights *

8. I get tired easily when I am physically active *

9. I feel pain ALL OVER my body *

10. I have headaches *

11. I have discomfort in my bladder and/or burning when I urinate *

12. I do not sleep well *

13. I have difficulty concentrating *

14. I have skin problems such as dryness, itchiness or rashes *

15. Stress makes my physical symptoms get worse *

16. I feel sad or depressed *

17. I have low energy *

18. I have tension in my neck and shoulders *

19. I have pain in my jaw *

20. Certain smells, such as perfumes make me feel dizzy and nauseated *

21. I have to urinate frequently *

22. My legs feel uncomfortable and restless when I am trying to get to sleep of a night *

23. I have difficulty remembering things *

24. I suffered trauma as a child *

25. I have pain in my pelvic area *

We would now like you to complete following section. Have you ever been diagnosed with one of the following disorders? Please tick the box if you have

CSI-Part B *

Restless Legs Syndrome
Chronic Fatigue Syndrome
Fibromyalgia
Temporo-mandibular Joint Disorder
Migraine or Tension Headache
Irritable Bowel Syndrome
Multiple Chemical Sensitivities
Neck Injury (including Whiplash)
Anxiety or Panic Attacks
Depression
Persistent Postural-Perceptual Dizziness

Comment

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Call Us: 0395987787
Email Us: smallstreetchiro@gmail.com

Services

Spine-Related Balance Disorders
Complex Care Chiropractic Services
Chiropractic Services
Free Balance Check

Our People

Paul Noone
Tony Cassis
Joan Noone

Business Hours

Monday: 9am-7pm
Tuesday: 9am-7pm
Wednesday: 9am-7pm
Thursday: 9am-7pm
Friday: 8am-12pm