Physiotherapy Intake Form

Physiotherapy Intake Form
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile
Email
example@example.com
Phone
Do you have a pension card?

YesNo
Do you have private health insurance?

YesNo
If yes, please provide name and card number
Doctor/Referrers name?
Medicare Number and expiry date
Emergency Contact
Emergency Contact Number
Please enter a valid phone number.
Relationship to Client?
Client Occupation?
Sports/hobbies you are involved with?
What is the reason for presenting to Cross Care today?
The following information, overleaf, will ensure we optimise your outcome and deliver physiotherapy

As a physiotherapy practice providing comprehensive care, our goals are:

1. To address the issues that brought you to Cross Care.

2. To treat the causes of your condition (not just treating the symptoms or find a temporary solution

3. To offer you the opportunity of improved health potential and wellness services in the future.
How long have you been experiencing this problem?
Have you experienced this problem previously?

YesNo
Please select the words that best describes your pain:

AchyBurningPins & NeedlesTinglingWeaknessNumbness
Since The injury began - please select

About the sameGetting BetterGetting Worse
What aggravates your symptoms?
What makes it feel better?
What makes it worse?
List of medications
Do you have or ever had

DiabetesDislocationsPregnantRheumatoid arthritisSpinal traumaHeart complicationsPacemakerOsteoarthritisOsteoporosisHigh blood pressureJoint replacementsRecent nauseaBladder/Bowel issuesDizzinessCartilage injuriesAnkylosing spondylitisLigament injuriesImplantsUnexpected weight lossSpinal surgeryStrokesSpinal fractureAneurysmCancers
W: www.crosscarendis.com.au E:admin@crosscarendis.com.au

P: 02 8074 1888 M: 0416 204 394

Clinic Policy

Our goal is to deliver an exceptionally friendly and professional service providing you with the best in physiotherapy care.

RECOVERY

Remember that healing and recovery takes time and not everyone heals/recovers at the same rate. If at any stage during your care, you do not feel that you are responding as well as expected, please discuss this with your physiotherapist. We want you to get the most from your care at Cross Care.

REFERRALS

The greatest compliment we can receive is the referral of a friend or family member. We look forward to assisting you and trust that your experience here is a positive one.

APPOINTMENT SCHEDULING

Your physiotherapist will outline a recommended action plan as the best plan for your injury. You will achieve the maximum results when you keep your recommended action plan to this schedule. To receive the most out of your care, and to save time, we ask that you schedule your appointments when receiving your plan.

MISSED APPOINTMENTS

Please allow 24 hours notice that will allow rescheduling to other patients/clients in need. Missed appointments will set you back in your recovery as well as others.

X-RAY AND OTHER SCANS

Our team/physiotherapist can obtain your recent radiology scan results. Please inform our receptionist if you have had any imaging completed for body areas relevant to your appointment today. Your signature below gives consent for APM to obtain your scan results.

CORRESPONDENCE

Our physiotherapist/s will contact your nominated Doctor to inform them of your progress. At Cross Care, we believe in building a team of health care professionals to best achieve your health goals. Your signature below indicates that you give permission to the therapist to exchange information with your Doctor, Allied Health Practitioners, Medical Specialists, Lawyers, and third party (insurance/Workcover) Case Managers, and allow access to My Health Record when necessary. This information will be confidential. I consent to Cross Care utilising technology including photography/videography, with careful storage of my images.
Treatment Consent

Physiotherapy treatment is an effective and safe form of treatment however like any treatment there are benefits and risks. Physiotherapists in this practice will discuss your condition and options for treatments with you so that you are appropriately informed and can make decisions relating to treatment. You may choose to consent or refuse any form of treatment for any reason including religious or personal grounds.

Typical physiotherapy carries a remote possibility of injury to structures such as but not limited to; nerves, bones, muscles, ligaments, discs or arteries. Physiotherapy can occasionally cause local swelling, bruising or transient increases in pain or other symptoms. Electro-physical agents such as ultrasound or interferential therapy have been linked to minor burns and abnormal skin reactions. Allergic skin reactions to cream, tape, or needles are a possibility.

You will be asked to expose the injured body part for assessment and treatment. Please inform your physiotherapist if you feel uncomfortable at any time, as alternative methods are available. Your physiotherapist may ask personal questions relating to your injury and how your injury impacts on your activities of daily living. The more information you provide, the more likely it is that the physiotherapist can provide effective treatment. If you feel uncomfortable with a particular question please let the physiotherapist know. You have the right to a second opinion at any time. The large array of skills in our team allows this to occur easily. Please contact your physiotherapist immediately if you experience adverse reactions. It is important to attend follow-up appointments as arranged by your physiotherapist to allow completion of your course of planned treatment.
The above must be at least 18 years of age, otherwise consent from a custodial parent is required to treat a minor. Your signature confirms that you have read and give consent to Cross Care Clinic Policy.
Signature

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Date

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Date
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