Client Intake Form - Virtual Physiotherapy
Date
I. Personal Information
First Name
Last Name
Date of Birth
Gender
Contact Information
Phone Number
Email Address
Street Address
City/Suburb
State/Province
Postal/Zip Code
Preferred Method of Communication
Emergency Contact
Full Name
Phone Number
II. Medical History
Primary Reason for Seeking Physiotherapy:
Date of Onset of Current Issue:
Description of Current Symptoms (Location, Intensity, Duration, Frequency):
Have you had any previous physiotherapy or other treatments for this issue?
If yes, please describe:
List any current medical conditions:
List any past surgeries or hospitalizations:
List any current medications (Prescription, Over-the-Counter, Supplements):
Do you have any known allergies?
If yes, please specify:
Do you experience any of the following? (Check all that apply)
Numbness/Tingling
Dizziness/Vertigo
Unexplained Weight Loss/Gain
Bowel/Bladder Changes
Fever/Chills
Severe Night Pain
Other (Please specify):
Have you been diagnosed with any mental health conditions? (Anxiety, Depression, etc.)
If so please list:
III. Lifestyle and Activity
Occupation:
Typical Daily Activities:
Level of Physical Activity:
Sedentary
Light
Moderate
Vigorous
Other (Please specify)
Specific Sports or Activities You Participate In:
Do you experience pain during any specific activities?
If yes, please describe:
Describe your typical work setup (Desk, Chair, Computer, etc.):
Do you smoke?
Do you consume alcohol?
If yes, how often?
IV. Virtual Assessment and Treatment Suitability
Do you have access to a reliable internet connection?
Do you have a device with a camera and microphone (Computer, Tablet, Smartphone)?
Do you have a quiet and private space for your virtual sessions?
Do you have adequate space to perform exercises as instructed?
Do you have any concerns about participating in virtual physiotherapy?
If yes, please explain:
Are you comfortable with using video conferencing software?
Do you have access to any of the following items that could be used for exercises?
Resistance Bands
Light Weights/Dumbbells
Foam Roller
Exercise Mat
Other (Please specify)
V. Treatment Options and Suitability Questions
Exercise Therapy:
Are you willing and able to follow a prescribed exercise program at home?
Do you have any limitations that would prevent you from performing exercises?
If yes, please explain:
Education and Self-Management:
Are you interested in learning about your condition and how to manage it?
Are you comfortable with receiving educational materials and instructions via email or video?
Posture and Ergonomic Advice:
Are you interested in receiving advice on posture and ergonomics?
Are you willing to make adjustments to your workspace or daily habits based on recommendations?
Pain Management Strategies:
Are you interested in learning pain management techniques (e.g., breathing exercises, relaxation techniques)?
Do you have any issues with skin sensitivity that would restrict the use of heat or cold therapy?
Are you taking any blood thinners?
Movement Analysis and Correction:
Are you willing to perform movements on camera so that your therapist can analyze your movement patterns?
Are you willing to receive feedback and corrections on your movement patterns?
VI. Informed Consent and Agreement
I understand that virtual physiotherapy has limitations compared to in-person treatment.
I understand that my physiotherapist will make every effort to provide safe and effective treatment, but I am responsible for performing exercises and following instructions as directed.
I understand that all information shared during virtual sessions will be kept confidential, except as required by law.
I consent to participate in virtual physiotherapy sessions and agree to the treatment plan developed by my physiotherapist.
I understand that I am responsible for my own safety during virtual sessions.
I acknowledge that I have read and understood this form and have had the opportunity to ask questions.
Client Signature:
Form Template Insight
Form Template Insight
Please remove this form template insight section before publishing.
Important Considerations:
- This form should be reviewed and updated regularly.
- Ensure compliance with all relevant privacy laws and regulations (e.g., HIPAA, GDPR).
- Clearly outline the technology requirements and provide technical support information.
- Establish a clear communication protocol for scheduling, rescheduling, and cancellations.
- Clearly state the cost of the session, and the payment methods accepted.
- Have a clear policy on what to do if the virtual session is disrupted by technical problems.
- If the therapist feels that a patient is not a good fit for telehealth, they should refer the patient to in person care.
- Have a plan for how to handle emergency situations.
This comprehensive form will help you gather essential information and determine the suitability of virtual physiotherapy for your clients. Remember to adapt it to your specific practice and client population.
Let's break down the client intake form and delve into the insights behind each section:
1. Personal Information:
Purpose:
- Establishes basic client identification and contact details.
- Ensures accurate record-keeping.
- Provides emergency contact information.
Insights:
- Preferred Communication: Understanding the client's preferred method is crucial for effective communication and engagement.
- Emergency Contact: This is vital for safety, especially in case of unexpected events during or after a virtual session.
2. Medical History:
Purpose:
- Gathers information about the client's current condition and past medical history.
- Identifies potential contraindications or red flags.
- Helps to understand the root cause of the musculoskeletal issue.
Insights:
- Detailed Symptom Description: This allows the physiotherapist to understand the nature, severity, and progression of the client's condition.
- Previous Treatments: Understanding past treatments helps to avoid duplication and identify effective strategies.
- Red Flag Questions: The check-box questions about numbness, dizziness, bowel/bladder changes, etc., are essential for identifying potential serious medical conditions that may require referral to a physician.
- Mental Health: Musculoskeletal pain and mental health are often interconnected. Understanding this connection allows for a more holistic approach to treatment.
3. Lifestyle and Activity:
Purpose:
- Provides context for the client's daily habits and physical demands.
- Helps to identify contributing factors to the musculoskeletal issue.
- Informs the development of a personalized treatment plan.
Insights:
- Occupation and Daily Activities: These factors can significantly impact musculoskeletal health.
- Activity Level: Understanding the client's current activity level helps to tailor exercises and rehabilitation strategies.
- Work Setup: Ergonomic factors are crucial for preventing and managing musculoskeletal pain.
- Habits (Smoking/Alcohol): These habits can affect healing and overall health.
4. Virtual Assessment and Treatment Suitability:
Purpose:
- Determines the client's readiness and ability to participate in virtual physiotherapy.
- Identifies any potential barriers to virtual care.
- Ensures the client has the necessary technology and environment.
Insights:
- Technology Access: Reliable internet and devices are essential for successful virtual sessions.
- Privacy and Space: A quiet and private space is crucial for confidentiality and effective treatment.
- Equipment Availability: Access to basic exercise equipment can enhance the effectiveness of virtual sessions.
- Comfort with Technology: The patient must feel comfortable with the technology being used.
5. Treatment Options and Suitability Questions:
Purpose:
- Educates the client about the available treatment options.
- Gauges the client's willingness and ability to participate in specific treatments.
- Ensures informed consent.
Insights:
- Exercise Therapy: Assessing the client's ability to perform exercises is crucial for safety and effectiveness.
- Education and Self-Management: Empowering clients with knowledge and self-management strategies is a key component of rehabilitation.
- Posture and Ergonomics: Addressing postural and ergonomic factors can prevent recurrence of musculoskeletal issues.
- Pain Management: Providing clients with pain management techniques can improve their quality of life.
- Movement Analysis: The patient must be willing to show their movements, and accept feedback.
6. Informed Consent and Agreement:
Purpose:
- Ensures the client understands the risks and benefits of virtual physiotherapy.
- Obtains the client's informed consent.
- Establishes a clear understanding of responsibilities.
Insights:
- Limitations of Virtual Care: Transparency about the limitations of virtual physiotherapy is essential.
- Client Responsibility: Emphasizing the client's role in following instructions and performing exercises is crucial.
- Confidentiality: Reassuring clients about the confidentiality of their information is vital.
- Safety: The patient must understand that they are responsible for their safety during the session.
Overall Insights:
- Client-Centered Approach: The form emphasizes gathering information about the client's individual needs and preferences.
- Risk Management: The form includes questions and statements designed to identify and mitigate potential risks.
- Effective Communication: The form promotes clear and open communication between the physiotherapist and the client.
- Holistic Assessment: The form addresses physical, mental, and lifestyle factors that can impact musculoskeletal health.
- Legal and Ethical Considerations: The form includes informed consent and confidentiality statements to ensure compliance with legal and ethical standards.
- Telehealth Specifics: The form focuses on the unique considerations that must be taken into account when providing telehealth Services.
By carefully considering these insights, physiotherapists can use the client intake form to provide safe, effective, and personalized virtual physiotherapy services.
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