The National Council for Osteopathic Research, SDC Version 2.0 Page 1
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- Percival Beasley
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1 SDC Data Collection Tool Part 1: Initial consultation for new episode To be completed by the osteopath Practitioner ID code 1. Date of first appointment 2. Sex: Male Female 3. Postcode: Please state first part only e.g. SE11, BN20 5. Patient s height Metres and cms* Feet and inches* *Circle as appropriate 7. What is the patient s main occupation? Not applicable 9. Does the patient receive disability allowance? Yes No Not applicable 4. Patient s age (years) 6. Patient s weight Kg and g* Stone and lbs* *Circle as appropriate 8. How would you describe the patient s current work status? (tick as appropriate) Working full time (employed) Working full time (self-employed) Working part time (employed) Working part time (self-employed) Not currently employed Retired Student Pre-school Other, please specify 10. How physically demanding is the patient s occupation? strenuous moderate light sedentary not applicable 11. How strenuous are the patient s leisure time activities? (see examples below) strenuous moderate light sedentary not applicable EXAMPLE LEISURE ACTIVITIES Sedentary: handicrafts, cinema Light: badminton, bowling, light gardening, walking (including to and from shops) Moderate: jogging, swimming, moderate gardening Strenuous: basketball, competitive cycling, competitive swimming, football, squash, heavy gardening 12. Who referred the patient to this practice? 13. Has the patient ever had any osteopathic treatment before? patient GP insurance company employer yes no NHS Consultant solicitor another healthcare practitioner 14. How did the patient hear about this practice? (tick all that apply) Word of mouth/recommendation Local advert Yell.com Yellow pages Thompson Directory I live nearby From a healthcare practitioner Internet search Other, please specify 15. Why did the patient decide to have osteopathy? (tick all that apply) Personal recommendation or referral Personal research Waiting for NHS physiotherapy appointment Failure of previous treatment Previous experience of osteopathic treatment Desire to have osteopathic treatment Wanted a form of manual or hands on treatment Did not want treatment through the NHS Wanted to have drug-free treatment Other, please specify The National Council for Osteopathic Research, SDC Version 2.0 Page 1
2 16. How long did the patient have to wait for the first appointment to be offered? Same day 2-3 days 4-7 days 8 days or more Not known 17. Is the patient on an NHS waiting list for treatment for this problem? 18. How long has the patient been waiting for NHS treatment for this problem? yes no Weeks Not applicable 19. How many times has the patient visited their GP about this problem prior to coming to here? times 20. How many weeks has the patient had this current problem? less than 1 week 1-2 weeks 3-4 weeks 5-6 weeks 7-12 weeks weeks 1 year or more 21. How many weeks has the patient been off work with this current problem? less than 1 week 1 week 2 weeks 3 weeks 4 weeks 5 weeks or more not applicable 22. Has the patient had previous treatment or investigations for this episode of this problem? Yes No If yes, has this included: Tick all that apply Imaging e.g. an X-Ray or scan Blood test Medication Urinalysis Hospital outpatient treatment Hospital inpatient treatment Other (please state) NHS Private 23. Type of onset of symptoms? Tick all that apply Acute/sudden onset (of unknown origin) Traumatic onset (of known origin) Slow/insidious onset Recurring problem 24. Is this the first episode? Please tick Yes, first time onset Second episode Third episode Fourth or more episodes 25. Severity of main symptoms on first visit for patient completion No symptoms Worst Moderate imaginable symptoms The National Council for Osteopathic Research, SDC Version 2.0 Page 2
3 26. Symptom areas: Please record up to four predominant symptom areas in order of priority for the patient 1 st 2nd 3rd 4th 1 Head/facial area 2 Temporo-mandibular 3 Neck 4 Shoulder 5 Upper arm 6 Elbow 7 Forearm 8 Wrist 9 Hand 10 Thoracic spine 11 Rib cage 12 Lumbar 13 Sacroiliac/pelvis/groin 14 Gluteal region 15 Hip 16 Thigh/upper leg 17 Knee 18 Lower leg 19 Ankle 20 Foot 21 Abdomen 22 Other 27. What current co-existing conditions (diagnosed by a medical practitioner) does the patient have (tick all that apply) Anaemia Angina CHF (Congestive heart failure) Hypertension MI (myocardial infarct) Peripheral vascular disease Stroke/TIA (Transient Ischaemic Attack) Anxiety Depression Dementia Migraine Neurological disease Arthritis Osteoporosis Asthma COPD (chronic obstructive pulmonary disease) Cancer Diabetes Hearing impairment Visual impairment Kidney disease Liver disease Pregnancy Bowel disease Upper gastrointestinal disease Other (please state) None Part 2: Management and treatment 28. What treatment plan was agreed with the patient? Osteopathic management Non-osteopathic treatment Single consultation only Patient referred on 29. What types of treatment approaches have been used with the patient today? No hands on treatment Soft tissue Articulation HVLA thrust Cranial techniques Muscle energy Strain/counterstrain Functional technique Visceral Myofascial release (MFR) Education Relaxation advice Steroid Injection Acupuncture Dietary advice Exercise Orthotics Lifestyle advice Other (please name) The National Council for Osteopathic Research, SDC Version 2.0 Page 3
4 Part 3: Information and Consent (this information will be treated in strict confidence ) 30. How was consent gained for examination? 31. How was consent gained for treatment? Implied consent Verbally Written Written and verbal Not applicable Other Implied consent Verbally Written Written and verbal Not applicable Other 32. Were any of the following procedures conducted and was specific consent obtained? Conducted Consented Yes No Yes No N/A Per rectal Per vaginal Oral Cervical HVT Lumbar HVT Thoracic HVT 33. Did you discuss with the patient Yes No N/A Treatment options for their problem? Possible risks and side effects of treatment The anticipated response to treatment The anticipated number of treatments Ways to avoid recurrences in the future? An explanation of the presenting problem? 34. What self-management strategies have been recommended for the patient to use? None Application of heat Application of cold Contrast bathing Rest Specific exercise General exercise Other (please state) 35. Who is responsible for payment for treatment Vitamins or other nutritional supplements Use of Back Book Use of Whiplash Book Natural remedies Naturopathic neuromuscular techniques Relaxation advice Advice concerning physical activity 36. Is an insurance case or litigation claim pending? Self Insurance company Employer/own company Referral by NHS Other (please state) Yes No 37. Time allocated for first appointment minutes The National Council for Osteopathic Research, SDC Version 2.0 Page 4
5 Part 4. Second appointment 38. After the first appointment, did the patient report any complications of treatment within the first 48 hours? 39. What was the patient s overall outcome after the first appointment? None of these Increased pain Increased stiffness Dizziness Nausea Headache Fatigue Drowsiness Serious adverse event, if known, please describe below Worst ever Much worse Worse Not improved/not worse Improved Much improved Best ever 40. What types of treatment approaches have been used with the patient? Please tick all that apply No hands on treatment Soft tissue Articulation HVLA thrust Cranial techniques Muscle energy Strain/counterstrain Functional Visceral Education Relaxation advice Steroid Injection Acupuncture Dietary advice Exercise Orthotics Myofascial release (MFR) Other (please name) 41. What self-management strategies have been recommended for the patient to use? Please tick all that apply None Application of heat Application of cold Contrast bathing Rest Specific exercise General exercise Other (please state) Vitamin or other nutritional supplements Use of the Back book Use of the Whiplash book Natural remedies Naturopathic neuromuscular techniques Relaxation advice Advice concerning physical activity 42. Time allocated for follow up appointments minutes Part 5: Last visit of initial course of treatment for this episode 43. Date of final visit: 44. Total number of treatments for this episode to date: 45. Has the patient completed the initial course of treatment for this episode? Yes No, treatment is ongoing Patient did not return (reason unknown) Treatment terminated due to illness Treatment terminated due to finance Treatment terminated for other reason (please state) 46. Severity of main symptoms on last visit for patient completion No symptoms Worst imaginable Moderate symptoms The National Council for Osteopathic Research, SDC Version 2.0 Page 5
6 47. Is the patient continuing to report any complications of treatment None of these Increased pain Increased stiffness Dizziness Nausea Headache Fatigue Drowsiness Serious adverse event, if known, please describe 48. What was the patient s overall outcome at their final appointment or to date? Worst ever Much worse Worse Not improved/not worse Improved Much improved Best ever 49. How many treatments did the patient have before being able to return to work? Not applicable (retired) Not applicable (not off work) Not applicable (not able to return to work) 50. Did you contact the patient s GP during this course of treatment? Yes No If yes, reasons for contact Patient was referred by the practice To request further information or investigation Other (please specify) GP had requested information To request referral for other treatment To provide the GP with information 51. At the last treatment, what was agreed for the patient s future care? None planned. Patient was discharged Patient opted to return for episodic care Patient awaiting results of investigation Patient was referred on for investigation/treatment Still continuing initial course of treatment Patient planning to return for further treatment Other (please state) 52. If the patient was referred on from your practice, where were they referred to? Their GP Other medical consultant Other practitioner (please state) 53. If the patient was referred for other treatment while still having osteopathic treatment, where were they referred to? Their GP Other medical consultant Other complementary practitioner Physiotherapist or podiatrist A counsellor Exercise trainer or class Other (please state) 54. To which ethnic group does the patient belong? (this question is optional: the information is intended to try and serve all groups equally) White British Irish Any other White background, please record Asian or Asian British Indian Pakistani Bangladeshi Any other Asian Chinese or other ethnic group Chinese Any other, please record background, please record Mixed White and Black Caribbean White and Black African White and Asian Any other Mixed background, please record Black or Black British Caribbean African Any other Black background, please record Thank you for completing this form The National Council for Osteopathic Research, SDC Version 2.0 Page 6
7 Statement of accreditation This standardised data collection tool has been produced by the National Council for Osteopathic Research (NCOR), and funded by the General Osteopathic Council (GOsC), the UK regulator of osteopaths. The intellectual property rights in the standardised data collection tool are jointly owned by the NCOR and the GOsC. The tool should be referenced in published work as: Moore AP, Leach CMJ, Fawkes CA. Standardised data collection tool for osteopathic practice. National Council for Osteopathic Research (UK) and General Osteopathic Council UK, The National Council for Osteopathic Research, SDC Version 2.0 Page 7
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CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
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Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
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ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.
203-610-2681 New Patient Intake Form Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. Name: Last Name First Name Today s date: Address:
Sarcoidosis Registry Proforma
Patient Demographics Patient Data Has a patient consent form been completed? 1.1 Title Mr 1.2 1.3 Forename(s) PlainText Surname PlainText 1.4 Gender Male 1.5 1.6 1.7 1.8 1.9 Mrs Ms Miss Dr Other
New Patient Form Date:
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Patient Health History Questionnaire
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Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
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Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
I choose not to specify
Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
Audit investigating In-house osteopathic provision at Silverdale medical practice
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