Please rate your pain by circling the one number that best describes your pain...

"0" being "No Pain" to "10" as "Pain as bad as you can imagine"

Circle the one number that describes how, during the past 24 hours. PAIN HAS INTERFERED with your:

"0" means "Does Not Interfere" as "10" means "Completely Interferes"

Here’s An Easy Way to Show You Care

Thank you for your kind referral, please also fax us a copy of patient’s health summary with their current medication and medical history at (02) 8088 7877

PO Box 18 Roslyn Street, Potts Point 2011 NSW
Phone 02 8866 1393
Fax 02 8088 7877
Healthlink: tzechowc


Thank you for submitting the consultation form. We look forward to seeing you at your appointment.

If you would like to upload further information or talk to one of us, please contact
02 8866 1393