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
*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

Other
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
*DETAILS OF PREVIOUS BABY WEIGHTS
*PREGNANCY RELATED ISSUES (now or in past pregnancies): tick all that apply

Other
*STATUS OF CURRENT PREGNANCY: Tick all that apply.

Other
*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.
*COMPLICATIONS?
*BABY'S WEIGHT
*GENDER OF BABY AND NAME:
*TYPE OF FEEDING
*NUMBER OF PREVIOUS BIRTHS
*DATE OF POSTNATAL CHECK:

MonthDayYear
Date
*PREVIOUS BIRTH TYPES: tick all that apply
*ABDOMINAL MUSCLES' STATUS:

Other
*PELVIC HEALTH STATUS: tick any that apply

Other
*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
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: