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Screening Form

The document is a screening form for Direct Access Physical Therapy that collects personal information, contact reasons, and health problems of the client. It includes a section for assessing the 'sense of alarm' and provides conclusions regarding further physiotherapeutic assessment. The form also requires the physiotherapist's name, date, signature, and client agreement to share the information with a doctor.

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loic.fontana1
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8 views1 page

Screening Form

The document is a screening form for Direct Access Physical Therapy that collects personal information, contact reasons, and health problems of the client. It includes a section for assessing the 'sense of alarm' and provides conclusions regarding further physiotherapeutic assessment. The form also requires the physiotherapist's name, date, signature, and client agreement to share the information with a doctor.

Uploaded by

loic.fontana1
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Screening form & Direct Access Physical Therapy

Personal information of the client


Name :__________________ Date of birth: _______________________
Address :__________________ Zip-code and City: _______________________
Date :__________________

Contact Reason physiotherapist

Contact reason:
______________________________________________________________

Major health problems:


___________________________________________________________________________

Course of the healthproblems:


______________________________________________________________

Screening on ‘sense of alarm’ or ‘no sense of alarm’

If “sense of alarm”, reason(s):


______________________________________________________________

Conclusion

■ Further physiotherapeutic assessment is not indicated, no referral to others


■ Further physiotherapeutic assessment is not indicated, cliënt is advised to
contact the GP
■ Further physiotherapeutic assessment is indicated
■ Further physiotherapeutic assessment is indicated, but I would like to have
additional information:
■ -Question:____________________________________________________________
■
■ Further physiotherapeutic assessment is indicated, cliënt will be referred to
fellow physiotherapist:
Name:_______________________________________________________________
Notes:_______________________________________________________________
Other notes:
_______________________________________________________________________

Name Physiotherapist: Date: Signature:

Yes No
The contents of this screening and reporting form is discussed with client  
Client agrees to send this form to the doctor  

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