Client Record Form

Medical in Confidence CONFIDENTIAL CLIENT RECORD FORM Client Details Date:……………………… (Mr/Mrs/Miss/Ms)……………… Surname:….……….…………..…………….First Name:…………. ……………………...

DoB:……………………..... Male □ Female □ Height:……………………Weight: …………………….. Address: ……………………………………………………………………………………………………………………………. Contact Numbers: Home:………….…………..... Work:….………………………… Mobile: …………………………….. In case of an emergency contact: Name:..……………………..……...... ….…Contact Number: …………………………….. Relationship: ……………………

Client Lifestyle Details

Occupation: ……………………………………….… ………………… Full-Time □ Part-Time □

GP Name: ……………………………………….………….. GP Contact Number: ……………………………………….…… GP Surgery Address: ……………………………………………………………………………………………………………… Exercise Routine: …………………………………………………………………………………………………………………… Sports:………………………………………………………Hobbies/Interests: ……………………………………………….....

Client Medical History

Have you recently visitited: GP □ Consult □ Physio □ Osteo □ Chiro □ Sports Ther □ Pod □ Msg Ther

□ Other Details: …………………………………………………………………………………………………………………………… …..

Are you currently taking any medications? Yes □ No □ Details: …………………………………………………………... Main reason for attending: ………………………………………………………………………………………………………….

Contraindications: Please state yes or no if you currently have, or have had in the past 6 months, any of the following symptoms / conditions:

Musculo-Skeletal Problems: Yes □ No □ eg. Strains / Sprains / Fractures / Myositis / Joint Replacement / Arthritis / Osteoporosis / Bursitis / Tendonitis / other Circulatory Problems: Yes □ No □ eg. Heart Condition / Hypertension / Hypotension / DVT / Phlebitis / Varicose Veins / Haemophilia / CV disease / other Neurological Problems: Yes □ No □ eg. Epilepsy / Sciatica / Neuralgia / MS / Parkinsons / other Skin Problems: Yes □ No □ eg. Eczema / Acne / Athletes Foot / Warts / Dermatitis / Psoriasis / Impetigo / Cuts / Bruises / Burns / Undiagnosed Lumps / other Respiratory Problems: Yes □ No □ eg. Asthma / Pneumonia / Bronchitis / Sinusitis / Cold / Cough / Flu / other Immune Problems: Yes □ No □ eg. Cancer / Rheumatoid Arthritis / HIV / AIDS / other Digestive Problems: Yes □ No □ eg. IBS / Constipation / Diarrhoea / Gall Stones / Kidney Stones / Urinary Tract Infection / other Miscellaneous Problems: Yes □ No □ eg. Diabetes/Allergies/Recent Operations/Major Operations/Pregnancy/Unstable Pregnancy/Glandular Fever/Headaches/Psychological Problems/Menstrual Problems/Substance Abuse/Feeling Unwell/other

Additional Details:……………………………………………………………………………………………..…………………… Has permission been requested or given by GP/Consultant to carry out the treatment? Yes □ No □ I hereby confirm that the information stated above is accurate to the best of my ability. I further fully understand that thorough and honest responses to these questions are essential to my safety. I undertake to inform my therapist of any changes to the above information. Signed:………………………………………………………………………………. Date:…………….……………………… I understand that an assessment needs to take place in order to establish a treatment plan. All assessment and treatment procedures have been thoroughly explained and I am happy to proceed. Signed:………………………………………………………………………………. Date:…………………………………… Therapist Signature: ……………………………………………………………..…. Date:…………………………………... Subjective Assessment …………………………………………………………………………………………………… ……… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… ……………………………….

Body Chart

Present complaint Notes: [pain distribution / severity / abnormalities]

General Observation [inc. posture / gait] ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………

Ranges of Movement Joint / Move Active Symptoms Pass Symptoms Resis Symptoms Region -ment -ive -ted Continue on separate sheet if necessary Functional Positive Negative Comments [eg. symptoms / L or R] Tests

Palpation

…………………………………………………………………………………………………… …….… …………………………………………………………………………………………………… ……. …………………………………………………………………………………………………… ………. …………………………………………………………………………………………………… ………….

Soft Tissue Symptoms [Problem List] / Action Plan

Symptom Therapist Action Symptom Client Action

Therapist Signature ……………………………………………………………….. Date……………

Client’s Signature (Informed Consent) …………………………………… …….Date…………….

Treatment and Post Care Advice Provided / Client Review

Date:………………………… Therapist Name: Treatment: …………………………………………………...... ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………

Therapist Signature:…………...... Date:………………………… Post Care Advice: ……………………………………………………………………………………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………… ………………………………………………………………………………………………… ……… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ……… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ……… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ……… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ……… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ………… ………………………………………………………………………………………………… ……… ………………………………………………………………………………………………… ………… Therapist Signature:………………………………………………………. Date:………………….