Initial Assessment Date. Therapist... PHYSIOTHERAPY ASSESSMENT FORM. Patient Details. Name. Address. Post Code.. Telephone Home.
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1 Initial Assessment Date Therapist... PHYSIOTHERAPY ASSESSMENT FORM Patient Details Name. Address. Post Code.. Telephone Home Telephone Work Mobile Date of Birth.. GP / Consultant. GP s Address... Source of Introduction. Preferred Language.
2 Present Complaint Please mark on the diagrams above where your present complaint is.
3 Patient Health Questionnaire Please fill in the following details. Any past Medical History (Operations, Accidents, Illnesses). If so what & when? Social History (Work, family commitments, hobbies, exercise levels)? Are you taking any medication, if so what, what for and how much? Any General Health problems? If you have any difficulties with any of the following please tick the box. Diabetes Heart Sudden Weight Loss Epilepsy Chest Night Pain Blood pressure Altered Sensation Night Sweats Cholesterol Pins and needles Osteoporosis Pregnancy Cancer Dizzyness Steroids Bladder/Bowel Visual disturbance Contraceptive pill Tinnitus Retinal dysfunction Anticoagulants Nausea Difficult speech Vitamin deficiency Memory loss Difficulty swallowing Hypermobility Vagueness Drop attacks Body Mass Index>30 Diet Infections Blood clotting disorder Smoker Allergies Rheumatoid Arthritis Connective tissue condition Hormone Replacement Any Investigations e.g. (MRI, Blood tests, X-Ray and their outcomes)? Any Family History e.g. Heart Problems, Strokes-Transient Ischaemic Attacks, Rheumatology, Surgery, Peripheral Vascular Disease?
4 Previous treatment e.g. Physiotherapy, Chiropractic, Osteopathy, Medical etc. Consent In order to proceed with examination and treatment, I require your consent. Your consent is required for both assessment and for treatment. Each time I change hand position I require your consent. The important thing to realise is that you may withdraw your consent for assessment or treatment at any time. You just tell me to stop. If you don t understand or want any further explanations please just ask. In order for the treatment to be a success, in particular over the long term it is important that you understand what is being done and that you are aware why it is being done, so that you are enabled to manage the problem yourself and prevent re-occurrences. Your consent is required for all the different treatments. I have a responsibility to inform you of any risks involved when using any treatment. Usually with the style of physiotherapy employed within this practice it is possible to feel sore after the treatment, this generally confirms that the treatment is on the correct position, however if prolonged that perhaps the level of treatment is too much at that particular stage, and the level will be modified the next time that you are treated. Some people bruise more easily than others and it is possible that occasionally there can be a small area of bruising left if you are sensitive. In the event of there being a specific risk with an individual technique this will be discussed with you before application of the technique so that you can make an informed decision as to whether you are happy to have that done. Should you require a chaperone you are welcome to bring someone with you. I have read and understood the information relating to consent and am happy to continue with assessment and treatment, today and for any further treatment days. In the event of a technique with a higher risk I understand that I may be required to sign an additional form. Your consent is also needed for me to be able to provide your G.P./ insurance company/solicitor with a progress report. Signature... Date.
5 Please note there is a standard fee of 10 for cancellations with less than 24 hours notice and failure to attend with no contact will be charged the full fee.
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History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Patient Information. Refurredby. Emergency Contact. Have you ever had chiropractic care before? For what problem? No ----
Patient Information Name ----------------------------------------------------------- Address --------------------------------------------------------- City State Zip Home Phone -------------------------
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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PATIENT INTRODUCTION
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