Physio Re-Assessment Form | The Ryan Neuro Therapy Centre

Physio Re-Assessment Form *

First

Last

Please complete the following to ensure that we have the correct information on our records.

Email *

Contact Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth *

Ethnicity *

Emergency Contact Name *

What is the best number to contact them on? *

Their relationship to you *

GP Surgery Name *

MEDICAL HISTORY

Have there been any changes to your neurological condition/s in the last year? *

Yes
No

If you answered 'Yes', please give details

Have there been any changes to your medical history in the last year? *

Yes
No

If you answered 'Yes', please give details.

Please list all current medication. *

Please give details.

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

If Yes, when was your last vision test?

Have you had any problems with your hearing in the last year? *

Yes
No

If Yes, please give details.

Do you have problems with swallowing? *

Yes
No

Have your fatigue levels dropped in the last year? *

Yes
No

Do you have any pain? *

Yes
No

If Yes, please give details.

Has there been any change to your living arrangements e.g. carer input? *

Yes
No

If you answered 'Yes', please give details

PERSONAL HISTORY

Do you have any hobbies or interests?

Please give details

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.

Have you experienced any changes to urinary or bowel continence in the past year? *

Yes
No

If you answered 'Yes', are you known to the NHS Continence Team?

Yes
No

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

Please indicate if you have had any falls recently *

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? *

Are you aware of all the classes we offer? *

Yes
No

Would you like some advice on any other sessions? *

Yes
No

If 'Yes', please give further details

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

Additional information:

Please bring any hospital reports you have to your assessment.

Please wear comfortable clothes and suitable shoes to your assessment.

Your Re-Assessment

MEDICAL HISTORY

PERSONAL HISTORY

MOBILITY & PERSONAL CARE

Additional information: