You can always press Enter⏎ to continue
Welcome
Hi there, please fill out and submit this form.
14
Questions
START
Accessibility
Enabled Form
Language
English (UK)
Hebrew
Arabic
1
Patient ID number
*
This field is required.
Previous
Next
Submit
Press
Enter
2
Caregiver ID number
*
This field is required.
Previous
Next
Submit
Press
Enter
3
Date
-
Date
שנה
חודש
יום
Previous
Next
Submit
Press
Enter
4
Treatment No
*
This field is required.
Previous
Next
Submit
Press
Enter
5
Main reason for coming to treatment (symptoms)
What was the main reason for coming to treatment ?
Yes
No
Yes
No
Are there still signs of the symptom?
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
Not applicable
Impaired ability to perform an action
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
Not applicable
Impaired ability to perform an action
Previous
Next
Submit
Press
Enter
6
Other reason for coming to treatment (symptoms)
Please Select
Yes
No
Please Select
Please Select
Yes
No
Did you come to treatment for any other reason?
What was the other reason for coming to treatment ?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Are there still signs of the symptom?
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
Not applicable
Impaired ability to perform an action
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
Not applicable
Impaired ability to perform an action
Previous
Next
Submit
Press
Enter
7
Rate the following parameters (If relevant to the symptoms)
(1 the lowest to 10 the highest. If not applicable, select "not applicable")
Please Select
Yes
No
Please Select
Please Select
Yes
No
Is it relevant to your symptoms?
Range of motion
1
2
3
4
5
6
7
8
9
10
not applicable
Range of motion
Range of motion
1
2
3
4
5
6
7
8
9
10
not applicable
Range of motion (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Movement stiffness
1
2
3
4
5
6
7
8
9
10
not applicable
Movement stiffness
Movement stiffness
1
2
3
4
5
6
7
8
9
10
not applicable
Movement stiffness (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Degree of swelling
1
2
3
4
5
6
7
8
9
10
not applicable
Degree of swelling
Degree of swelling
1
2
3
4
5
6
7
8
9
10
not applicable
Degree of swelling (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Natural posture
1
2
3
4
5
6
7
8
9
10
11
12
Natural posture
Natural posture
1
2
3
4
5
6
7
8
9
10
11
12
Natural posture (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Muscle strength
1
2
3
4
5
6
7
8
9
10
not applicable
Muscle strength
Muscle strength
1
2
3
4
5
6
7
8
9
10
not applicable
Muscle strength (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Previous
Next
Submit
Press
Enter
8
3. If medication was taken, is there any change in the dosage or frequency?
Please Select
Yes
No
Please Select
Please Select
Yes
No
3. If medication was taken, is there any change in the dosage or frequency?
Specify
Previous
Next
Submit
Press
Enter
9
Did the client receive any other treatments?
Did the client receive any other treatments?
Yes
No
Did the client receive any other treatments?
Did the client receive any other treatments?
Yes
No
Did the client receive any other treatments?
Please Select
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
Please Select
Please Select
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
Specify
Previous
Next
Submit
Press
Enter
10
Were any test done since the beginning of treatments?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Were any test done since the beginning of treatments?
Please Select
Blood tests
Blood pressure tests
Radiology
Not applicable
Please Select
Please Select
Blood tests
Blood pressure tests
Radiology
Not applicable
Test 1
Results
Normal
Not Normal
Not applicable
Results
Results
Normal
Not Normal
Not applicable
Results 1
Please Select
Blood tests
Blood pressure tests
Radiology
Not applicable
Please Select
Please Select
Blood tests
Blood pressure tests
Radiology
Not applicable
Test 2
Please Select
Normal
Not Normal
Not applicable
Please Select
Please Select
Normal
Not Normal
Not applicable
Result 2
Please Select
Blood tests
Blood pressure tests
Radiology
Not applicable
Please Select
Please Select
Blood tests
Blood pressure tests
Radiology
Not applicable
Test 3
Please Select
Normal
Not Normal
Not applicable
Please Select
Please Select
Normal
Not Normal
Not applicable
Results 3
Previous
Next
Submit
Press
Enter
11
Were there any visits to the ER or hospitalizations during treatments?
Yes
No
Yes
No
Were there any visits to the ER or hospitalizations during treatments?
If so, please note
Previous
Next
Submit
Press
Enter
12
What is your clients rate for the following after the recovery journey.
Rate the following parameters from 1 the lowest to 10 the highest. If not applicable, select "not applicable".
Daily activities
1
2
3
4
5
6
7
8
9
10
Daily activities
Daily activities
1
2
3
4
5
6
7
8
9
10
Daily activities
Ability at Work
1
2
3
4
5
6
7
8
9
10
not applicable
Ability at Work
Ability at Work
1
2
3
4
5
6
7
8
9
10
not applicable
Ability at Work
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Rest
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Sleep
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Apatite
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
not applicable
General Well Being
Previous
Next
Submit
Press
Enter
13
Caregivers’ summary of the recovery journey
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
14
Caregivers’ recommendations
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
14
See All
Go Back
Submit
.65d310422f82d6.32916276.PNG)