TESTIMONIALS

George Michael
(Singer/Songwriter)

"I am delighted to recommend Simeon's work, I am sure you will all gain benefit from his new technique for treating your frozen shoulders."

READ FULL STORY

Feedback Form

Find a Practitioner > First Steps

All of our practitioners are highly qualified, we only accept Doctors, Osteopaths, Chiropractors and other medical practitioners who are on a professional register and hold their own indemnity insurance. We are committed to ensure that our practitioners offer you the highest levels of care and professionalism. In the unlikely event that you have a complaint we would very much appreciate your feedback in as much detail as possible. All information is treated with strict confidence.

You can fill the form online here, or download it as a PDF Document, print and complete the form and send it back to us.

Please return all printed forms to:
Frozenshoulder.com Ltd
108 Swains Lane
Corner 12 South Grove
Highgate
London, England

Note: TO BE COMPLETED AFTER YOUR LAST TREATMENT (or when advised by your therapist).

Form online. Complete the following fields:

You must complete all fields marked (*)

The SIS - Shoulder Impairment Scale - after Josh Wies PhD

Your Name:(*)

Your Gender: (*)

Date of birth: (*)

What is your age: (*)

Your Handiness:

Your Occupation:

How many weeks ago did your current shoulder problem start:

Do you have any current or past medical problems? (tick all that apply)

Heart:

Blood Pressure:

Breathing Difficulty:

Rheumathoid Arthritis:

Pregnancy:

Osteoporosis:

Broken Bone:

Unexplained Weight Loss:

Skin problems:

Seizures:

Neurological Disorder:

Blood Thinners:

Other (please specify):

How would you rate your general health:

Have you had any diagnostic tests of the shoulder? (tick all that apply)

X-Ray:

CT Scan:

MRI:

Arthrogram:

Nerve Conduction Test:

Other (please specify):

Prior episodes of shoulder problems:

Please list any medications you are currently taking:

Please rate your level of pain NOW on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst it can be:

Irritating factors: What activities or positions increase your pain?

Alleviating factors: What activities or positions relieve your pain?

Shoulder Pain and Disability Index (SPADI)

Disability Scale: How much difficulty do you have:
0 = no difficulty 10 = unable to do N/A = not applicable

Washing your hair?

Washing your back?

Putting on an undershirt or pullover sweater?

Putting on a shirt that buttons down the front?

Putting on your pants?

Placing an object on a high shelf?

Carrying a heavy object of 10 pounds?

Removing something from your back pocket?

About Your Treatment

How many months have you been suffering
with your frozen shoulder?

How many sessions did you have?

Was the treatment effective?

Did you try any other therapies before the
Niel-Asher Technique?

If yes, which ones?

Were they effective?

Did you try any other therapies whilst undergoing the Niel-Asher Technique?

If yes, which ones?

Were they effective?

About Your Therapist

What was the name of your therapist?

Were you happy with your therapist?

How did you find your therapist?

If newspaper or media, which one?

If you would like to write a testimonial about your therapist, enter it here: