BACKFIT PHYSIO REGISTRATION AND CONSENT FORM

REGISTRATION AND CONSENT FORM
BACKFIT PHYSIO PATIENT REGISTRATION AND CONSENT
HCPC registered physiotherapists have a legal and professional obligation to keep accurate records of any patient intervention. This requires Backfit physio to record some of your demographic information as detailed below. Physiotherapy records must be stored securely for 8 years from completion of treatment. For maternity records it is 25 years. After this timeframe they will be securely destroyed. Your records will be hard copies filed securely. Your information is confidential and will not be shared with a third party without your consent. During your appointments, you will be asked questions regarding your problem including symptoms and how they are affecting you, along with recording information regarding your medical history and medications. All information gathered is used to make clinical decisions regarding diagnosis and how best to help you.

Information is not shared with anyone unless you give permission to contact your GP regarding your health.
*FULL NAME:
*PREFERRED NAME
*DATE OF BIRTH
AGE
*OCCUPATION:
*ADDRESS
HOME TELEPHONE
*MOBILE NUMBER
*EMAIL ADDRESS
*PERMISSABLE METHODS OF CONTACT

HOME PHONEMOBILE PHONETEXTEMAILMESSENGER
*GP PRACTICE
*EMERGENCY CONTACT: NAME AND TELEPHONE NUMBER
*REASON FOR PHYSIOTHERAPY
*Please give details about what you would like help with:
*WHAT WOULD YOU LIKE TO ACHIEVE FROM PHYSIOTHERAPY?
*1. MEDICAL HISTORY, tick all that apply

NO MEDICAL ISSUESDiabetesEpilespyThyroidCancerHeartLungsCirculationHistory of TuberculosisHIV/AIDSSurgeryFracture/broken bonesNeurological conditionOsteoporosisContinence issuesOrgan ProlapseHistory of anaemiaUnexplained weight lossThoracic painChanges of sensation: pins and needles/numbnessBlood pressureOther
2. PREGNANT CLIENTS ONLY (please answer all):
*ESTIMATED DUE DATE:

MonthDayYear
Date
*Multiple pregnancy:
*PREGNANCY PLANNED CARE:
*NUMBER OF PREVIOUS PREGNANCIES
*NUMBER AND AGES OF CHILDREN
*PREVIOUS BIRTH TYPES: tick all that apply

NORMAL SPONTANEOUS VAGINAL DELIVERYCAESAEREAN SECTIONASSISTED DELIVERYPERINEAL TEAREPISIOTOMY
*DETAILS OF PREVIOUS BABY WEIGHTS
*PREGNANCY RELATED ISSUES (now or in past pregnancies): tick all that apply

PLACENTA PREVIABLOOD PRESSURE ISSUESPRE-ECLAMPSIA/HISTORY OF PRE-ECLAMPSIAGESTATIONAL DIABETESHISTORY OF SPOTTING OR BLEEDINGHISTORY OF ANAEMIAHISTORY OF INCOMPETENT CERVIXBABY GROWTH AND DEVELOPMENTHISTORY OF MISCARRIAGEHISTORY OF CONTINENCE ISSUESHISTORY OF PELVIC GIRDLE PAINNoneOther
*STATUS OF CURRENT PREGNANCY: Tick all that apply.

Pelvic girdle/Musculoskeletal painContinence issuesMarked fatigueMarked Nausea/vomiting/Hyperemesis GravidarumBleeding or spottingLeaking amniotic fluidIncompetent cervixLight headedness, faintness or dizzinessUnexplained abdominal painSudden swelling of ankles, hands or faceExcessive shortness of breath/chest painProblematic or persistent headachesSwelling, pain or redness of one calfReduced foetal movementpoor weight gainexcessive weight gainAnaemiaNoneOther
*WHAT ACTIVITY HABITS / EXERCISE HAVE YOU BEEN UNDERTAKING IN THIS PREGNANCY?
*LEVELS OF EXERCISE/ACTIVITY HABITS PRIOR TO PREGNANCY:
3. POSTNATAL CLIENTS ONLY:
*DATE OF DELIVERY

MonthDayYear
Date
*Multiple pregnancy:
*BIRTH TYPE: tick all that are applicable.

NORMAL SPONTANEOUS VAGINAL DELIVERYCAESAEREAN SECTIONASSISTED DELIVERYPERINEAL TEAREPISIOTOMY
*COMPLICATIONS?
*BABY'S WEIGHT
*GENDER OF BABY AND NAME:
*TYPE OF FEEDING

BOTTLEBREASTBOTH
*NUMBER OF PREVIOUS BIRTHS
*DATE OF POSTNATAL CHECK:

MonthDayYear
Date
*PREVIOUS BIRTH TYPES: tick all that apply

NORMAL SPONTANEOUS VAGINAL DELIVERYCAESAEREAN SECTIONASSISTED DELIVERYPERINEAL TEAREPISIOTOMYNOT APPLICABLE
*ABDOMINAL MUSCLES' STATUS:

Unsure/not been checkSuspect a separationBeen diagnosed with separatoinBeen diagnosed with a herniaOther
*PELVIC HEALTH STATUS: tick any that apply

NormalContinence issues daytimeContinence issues night timepainprolapse diagnosedprolapse suspectedOther
*WHAT DO YOU WANT TO WORK ON OR WORK TOWARDS?
*Any other information you feel is important:
DECLARATIONS AND CONSENT:

The information completed above is true to the best of my knowledge on the date of completion and understand this will be explored and recorded, in more detail, during my appointments/sessions. I have read the leaflet for preparing for my consultation/session.

I hereby give consent to the storage of my physiotherapy records for 8 years, or 25years for maternity records, from the completion of your physiotherapy episode of care. You understand that not providing consent to assessment, treatment and the storage of your records means Backfit physio will not be able to proceed with the consultation/sessions
Client Name (PRINT)
Client Signature

Clear
DATE

MonthDayYear
Date
Should be Empty:

REGISTRATION AND CONSENT FORM

BACKFIT PHYSIO PATIENT REGISTRATION AND CONSENT

2. PREGNANT CLIENTS ONLY (please answer all):

3. POSTNATAL CLIENTS ONLY: