Physio Assessment Form | The Ryan Neuro Therapy Centre

Name *

First

Last

Email *

Contact Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth *

Gender *

Female
Male
Non-binary
Prefer not to say

Ethnicity *

How did you hear about the Ryan Neuro Therapy Centre? (copy) *

Emergency Contact Name *

What is the best number to contact them on? *

Their relationship to you *

GP Surgery Name *

GP Surgery Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

MEDICAL HISTORY

Diagnosed neurological condition/s *

Date of diagnosis / onset of symptoms *

Have you been diagnosed by a neurologist *

Yes
No

Have you had previous therapy for this conditon? *

Yes
No

If you answered Yes, please list treatments

Do you suffer from any of the following (please tick all that apply) *

Please list all current medication *

Do you have any allergies *

Yes
No

If Yes, please list below and indicate whether an auto-inject medication is required

Do you have any problems with your vision? *

Yes
No

Do you have any problems with your hearing? *

Yes
No

Do you have problems with swallowing? *

Yes
No

Do you suffer from fatigue? *

Yes
No

Do you have any pain? *

Yes
No

PERSONAL HISTORY

Occupation

Activity - Please describe your daily routine *

Do you have any hobbies or interests *

MOBILITY & PERSONAL CARE

Equipment used for mobility (please tick all that apply) *

Please list additional equipment that you have at home, eg. Hospital bed, Hoist, Bed Lever, Raised Toilet seat, Trolley, Grab Rails, Stair Lift.

Do you require any help with personal care? *

Yes
No

If Yes, please indicate below

Help with bathing
Help with toileting
Help with dressing
Help with transfers

If you have ticked Yes to requiring help with toileting - do you have a carer who can attend the Centre with you? (We do not have enough staff at the Centre to assist with toileting needs) *

Yes
No
Not applicable

Please indicate if you have had any falls recently (copy) *

No falls/trips
Occasional falls/trips
Regular falls/trips

Are you able to negotiate steps / stairs *

Yes
No

What is your main reason for attending the Centre? *

Do you have any goals that you are hoping to achieve? *

AVAILABILITY

We have two sessions each day (Monday to Thursday). The morning session runs from 10am to 12noon and the afternoon from 12.30pm to 2.30pm. Please indicate when you would be available to attend. Please tick all that apply. *

Our current provision runs from Monday to Thursday. If we opened on a Friday from 10am to 1pm, would you be interested in attending? *

Yes
No

We offer a paid for Neuro 1-to-1 service. This is separate from our Membership. The cost is £60 for a 45-minute session, fully supported by one of our physio team. Please indicate if you would be interested in this service *

Yes
No

Additional information:

Please bring any hospital reports you have to your assessment.

Please wear comfortable clothes and suitable shoes to your assessment.

Your Initial Assessment

MEDICAL HISTORY

PERSONAL HISTORY

MOBILITY & PERSONAL CARE

AVAILABILITY

Additional information: