• SMART Triage Form

    Answer the questions about your symptoms and location so the form can guide you to the right next steps.

  • Patient Details

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • General Questions (Everyone)

  • Which Body Part?*
  • When did your symptoms begin?*
  • How did it start?*
  • Which best describes your symptoms?*
  • What makes it worse?

  • Red Flag Screen

  • Significant fall or accident?*
  • Unexplained weight loss?*
  • Fever or night sweats?*
  • History of cancer?*
  • Severe night pain?*
  • Sudden inability to walk?*
  • Loss of bladder or bowel control?*
  • Numbness around the saddle area?*

  • Knee Questions

  • Did it twist?*
  • Did it swell within 24 hours?*
  • Does it lock?*
  • Does it give way?*
  • Can you fully straighten your knee?*
  • Can you fully bend it?*
  • Can you walk?*

  • Ankle / Foot Questions

  • Were you able to walk immediately afterwards?*
  • Where is your pain?*
  • Is there swelling?*
  • Is there bruising?*
  • Can you stand on tiptoes?*

  • Shoulder Questions

  • Can you lift your arm above shoulder height?*
  • Did it dislocate?*
  • Night pain?*
  • Weakness?*

  • Neck Questions

  • Does pain travel into your arm?*
  • Pins and needles?*
  • Weakness?*
  • Problems with balance?*
  • Problems using your hands?*

  • Lower Back Questions

  • Pain into leg?*
  • Below knee?*
  • Numbness?*
  • Weakness?*
  • Bladder changes?*

  • Hip Questions

  • Pain in groin?*
  • Pain lying on side?*
  • Difficulty putting shoes/socks on?*
  • Clicking?*

  • Consent Form

  • I understand that:

    My assessment may include physical examination of the affected area and related regions
    Treatment may include manual therapy, exercise therapy, advice, or other physiotherapy interventions
    I may stop or withdraw consent at any time
    Risks and benefits of treatment will be explained to me
    My personal data will be stored securely in accordance with UK GDPR regulations
    Information may be shared with my GP or healthcare professionals if clinically necessary for my safety

    Section 3 – Medical Safety Confirmation
    Checkboxes:

    x I confirm I have provided accurate medical history information
    x I understand I should inform the clinician of any changes in my condition
    x I understand physiotherapy is not a substitute for emergency medical care
    x I consent to my data being stored for clinical purposes.

     

  • Appointment
  • Should be Empty: