Pro-Active Training (Form 1)
Patient Details
Date
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Patient Tel No:
-
Area Code
Phone Number
Patient Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age group:
Under 20
20 - 30
30 - 40
40 - 50
50 - 60
60+
Lifestyle:
Active
Sedentary
GP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
No. Of children (if applicable):
CONTRAINDICATIONS (select if/where appropriate):
Pregnancy
Cardio vascular conditions
Any condition already being treated by a GP or another health
Professional
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Any dysfunction of the nervous system (e.g. Muscular sclerosis,
Parkinson’s disease, Motor neurone disease)
Bells Palsy
Inflamed nerve
Cancer
Spastic conditions
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and
6 months for a small scar)
Sunburn
Hormonal implants
Abdominal pain
Haematoma
Hernia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
Medical History
MEDICAL HISTORY
Respiratory:
Gastro Intestinal
Genito Urinary:
Gynaecological:
Musculoskeletal:
Cardio Vascular:
Medications:
Illnesses:
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
Aggravating Factors:
Relieving Factors:
Onset
Onset:
When:
How:
Progression:
Any Treatment:
Radiation:
Frequency:
Character:
Observation:
Active and Passive Movements:
Palpation:
Special Tests:
Clinical Opinion for the Complaint:
Treatment
Treatment:
How patient felt after treatment:
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific home-care advice:
Reflective Practice:
SOAP Form 1
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
SOAP Form 2
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
Back
Form 2 →
Save
Pro-Active Training (Form 2)
Patient Details
Date
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Patient Tel No:
-
Area Code
Phone Number
Patient Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age group:
Under 20
20 - 30
30 - 40
40 - 50
50 - 60
60+
Lifestyle:
Active
Sedentary
GP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
No. Of children (if applicable):
CONTRAINDICATIONS (select if/where appropriate):
Pregnancy
Cardio vascular conditions
Any condition already being treated by a GP or another health
Professional
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Any dysfunction of the nervous system (e.g. Muscular sclerosis,
Parkinson’s disease, Motor neurone disease)
Bells Palsy
Inflamed nerve
Cancer
Spastic conditions
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and
6 months for a small scar)
Sunburn
Hormonal implants
Abdominal pain
Haematoma
Hernia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
Medical History
MEDICAL HISTORY
Respiratory:
Gastro Intestinal
Genito Urinary:
Gynaecological:
Musculoskeletal:
Cardio Vascular:
Medications:
Illnesses:
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
Aggravating Factors:
Relieving Factors:
Onset
Onset:
When:
How:
Progression:
Any Treatment:
Radiation:
Frequency:
Character:
Observation:
Active and Passive Movements:
Palpation:
Special Tests:
Clinical Opinion for the Complaint:
Treatment
Treatment:
How patient felt after treatment:
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific home-care advice:
Reflective Practice:
SOAP Form 1
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
SOAP Form 2
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
← Previous
Form 3 →
Save
Pro-Active Training (Form 3)
Patient Details
Date
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Patient Tel No:
-
Area Code
Phone Number
Patient Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age group:
Under 20
20 - 30
30 - 40
40 - 50
50 - 60
60+
Lifestyle:
Active
Sedentary
GP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
No. Of children (if applicable):
CONTRAINDICATIONS (select if/where appropriate):
Pregnancy
Cardio vascular conditions
Any condition already being treated by a GP or another health
Professional
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Any dysfunction of the nervous system (e.g. Muscular sclerosis,
Parkinson’s disease, Motor neurone disease)
Bells Palsy
Inflamed nerve
Cancer
Spastic conditions
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and
6 months for a small scar)
Sunburn
Hormonal implants
Abdominal pain
Haematoma
Hernia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
Medical History
MEDICAL HISTORY
Respiratory:
Gastro Intestinal
Genito Urinary:
Gynaecological:
Musculoskeletal:
Cardio Vascular:
Medications:
Illnesses:
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
Aggravating Factors:
Relieving Factors:
Onset
Onset:
When:
How:
Progression:
Any Treatment:
Radiation:
Frequency:
Character:
Observation:
Active and Passive Movements:
Palpation:
Special Tests:
Clinical Opinion for the Complaint:
Treatment
Treatment:
How patient felt after treatment:
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific home-care advice:
Reflective Practice:
SOAP Form 1
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
SOAP Form 2
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
← Previous
Form 4 →
Save
Pro-Active Training (Form 4)
Patient Details
Date
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Patient Tel No:
-
Area Code
Phone Number
Patient Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age group:
Under 20
20 - 30
30 - 40
40 - 50
50 - 60
60+
Lifestyle:
Active
Sedentary
GP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
No. Of children (if applicable):
CONTRAINDICATIONS (select if/where appropriate):
Pregnancy
Cardio vascular conditions
Any condition already being treated by a GP or another health
Professional
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Any dysfunction of the nervous system (e.g. Muscular sclerosis,
Parkinson’s disease, Motor neurone disease)
Bells Palsy
Inflamed nerve
Cancer
Spastic conditions
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and
6 months for a small scar)
Sunburn
Hormonal implants
Abdominal pain
Haematoma
Hernia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
Medical History
MEDICAL HISTORY
Respiratory:
Gastro Intestinal
Genito Urinary:
Gynaecological:
Musculoskeletal:
Cardio Vascular:
Medications:
Illnesses:
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
Aggravating Factors:
Relieving Factors:
Onset
Onset:
When:
How:
Progression:
Any Treatment:
Radiation:
Frequency:
Character:
Observation:
Active and Passive Movements:
Palpation:
Special Tests:
Clinical Opinion for the Complaint:
Treatment
Treatment:
How patient felt after treatment:
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific home-care advice:
Reflective Practice:
SOAP Form 1
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
SOAP Form 2
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
← Previous
Form 5 →
Save
Pro-Active Training (Form 5)
Patient Details
Date
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Patient Tel No:
-
Area Code
Phone Number
Patient Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age group:
Under 20
20 - 30
30 - 40
40 - 50
50 - 60
60+
Lifestyle:
Active
Sedentary
GP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
No. Of children (if applicable):
CONTRAINDICATIONS (select if/where appropriate):
Pregnancy
Cardio vascular conditions
Any condition already being treated by a GP or another health
Professional
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Any dysfunction of the nervous system (e.g. Muscular sclerosis,
Parkinson’s disease, Motor neurone disease)
Bells Palsy
Inflamed nerve
Cancer
Spastic conditions
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
CONTRAINDICATIONS THAT RESTRICT TREATMENT (select if/where appropriate):
Fever
Contagious or infectious diseases
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Skin diseases
Undiagnosed lumps and bumps
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abrasions
Scar tissues (2 years for major operation and
6 months for a small scar)
Sunburn
Hormonal implants
Abdominal pain
Haematoma
Hernia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
Medical History
MEDICAL HISTORY
Respiratory:
Gastro Intestinal
Genito Urinary:
Gynaecological:
Musculoskeletal:
Cardio Vascular:
Medications:
Illnesses:
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
Aggravating Factors:
Relieving Factors:
Onset
Onset:
When:
How:
Progression:
Any Treatment:
Radiation:
Frequency:
Character:
Observation:
Active and Passive Movements:
Palpation:
Special Tests:
Clinical Opinion for the Complaint:
Treatment
Treatment:
How patient felt after treatment:
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific home-care advice:
Reflective Practice:
SOAP Form 1
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
SOAP Form 2
SOAP FORM
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please highlight how intense the pain is for the patient:
No Pain
1
2
3
4
5
6
7
8
9
Worse pain possible
10
1 is No Pain, 10 is Worse pain possible
Please highlight where on the body the pain i using the pen tool:
How patient has been since last treatment:
Improving
No Change
Worsening
New Contraindications
How patient has been since last treatment (further explanation):
Observation:
Palpation:
A & P Movements:
Functional Tests:
Treatment Goals:
Treatment:
How patient felt after treatment:
Patient To Return After:
Number of days, weeks , months
Day / Week / Months
Please Select
Days
Weeks
Months
Home care (FID - frequency, intensity, duration):
Stretch
Strengthen
Postural
Heat
Cold
Specific Home-Care Advice:
Reflective practice:
Save
Submit
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