ALL NEW physiotherapy patients need to book by calling Kare Physio or booking via email at [email protected] Subsequent physio visits can be booked by Jane

Use your computer mouse to navigate from line to line on the form.  Only hit the "ENTER" key on your computer once you have totally completed the form. Hitting "ENTER" prematurely will cause the form to send.


Patient History




Frequency of Urination

Frequency of Bowel Movements

Fluid Intake

Bladder Leakage (Number of Episodes)

Bowel Leakage (Number of Episodes)

On average, how much urine do you leak?

On average, how much stool do you leak?