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Physio assessment form
complpilates
2023-05-24T10:39:16+01:00
Physio Assessment Form
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*
" indicates required fields
Client Name:
*
Presenting Condition (Current Symptoms)
Pins & Needles
Yes
No
Details:
Numbness
Yes
No
Details:
Aggs:
Eases:
24hr pain:
Night pain:
History of Presenting Condition
Special Qs Lx
Bladder disturbance?
Bowel disturbance?
Saddle anaesthesia?
Erectile dysfunction?
Loss of sensation during sexual intercourse?
Gait disturbance?
Pins and needles in both hands and feet?
Change to grip strength?
Special Qs Cx
Dizziness?
Drop attacks?
Diplopia?
Dysphagia?
Dysarthria?
Nausea?
Nystagmus?
Facial numbness?
Hoarseness?
Taste?
Smell?
Hearing?
Please give details of anything that was yes above:
Special Qs Peripheral Joints
Medical History
T (Thyroid)?
H (Heart)?
R (Rheumatoid)?
E (Epilepsy)?
A (Asthma)?
D (Diabetes)?
S (Surgery)?
C (Cancer)?
T (Trauma)?
BP?
Glaucoma?
Osteoporosis / Osteopenia?
Hernia?
Menopausal / Perimenopausal?
Migraines?
EDS?
Incontinence?
Recent Weight Loss?
Other and details:
Drug History
Steroids?
Anticoagulants?
Other:
Social History (Occupation & Leisure)
Expectations:
Goals:
PSFS:
Objective assessment:
Movement session:
Analysis:
Plan:
Instructor name
*
Comments
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