Evaluation Form

Personal Information

First Name
Last Name
Marital Status

Place of Birth

City
State / Province
Country
Date of Birth
Gender

Biometry

Height (metres/cm)
Weight (kg/ lb)

Home Address

Address
Postcode
Country
Time Zone
Phone Number
Fax
Cell / Mobile
Email Address

Current Condition

Primary Diagnosis
Date of Diagnosis
Other conditions
Current Medication Please include dosage, and any supplements you are taking

Current Symptoms
Known Allergies List all known allergies including medications, foods, etc:
Ambulation Aids What ambulation aids do you currently use?

Patient History

Medication List all medication taken within the last six months
Other illnesses List any other medical illnesses & surgical operations, with dates
Do you smoke?
Do you drink?

Previous treatment
Expectations What do you hope to achieve from this treatment?
How soon would you like to be treated?

Physical Limitations

How far can you walk before tiring?
Can you stand independently?
Is your vision affected by your condition?
Are you still able to write?
Are you able to read fine print?
Are your upper limbs/hands affected by your condition?
When travelling, do you have any special needs?
Do you require ADA Accomodation?
Do you require wheelchair access?
List any other special travelling needs
Do you need assistance with walking?
If yes do you need a wheelchair?
Can you transfer independently?
Do you need assistance with bathing?
Do you need assistance with dressing?
Do you need assistance with eating?
Do you need assistance with getting in & out of bed?
Do you need assistance with getting in & out of a car?
What social support assistance do you have in place?
How has your condition affected your mood & outlook on life?
If you are happy with the information you have supplied: