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Park House Spa Hydrotherapy Swimming Pool Reading UK

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4 Aquatic Therapy Evaluation Form

Patient Name *

First

Last

Patient Date of Birth *

DDMMYYYY

Phone Number

Email *

prevents Please doing.

Please advise whether initial assessment or follow up *

Initial Assessment
Follow Up Evaluation

Name of Person Completing Form *

Relationship to Patient *

Date of Completion *

DMMYYYY

Please state your symptom (physical or mental), which bothers you the most *

Symptom 1 Please consider how bad this symptom has been, over the last week, and score it by choosing a number (0 – no impact, 6 – maximum impact)

Selected Value: 0

For how long have you had Symptom 1?

0-4 weeks
4-12 weeks
3 months-1 year
1-5 years
Over 5 years

Please state your next symptom (physical or mental)

Symptom 2 Please consider how this symptom has been, over the last week, and score it by choosing a number (0 – no impact, 6 – maximum impact) (copy)

Selected Value: 0

For how long have you had Symptom 2?

0-4 weeks
4-12 weeks
3 months-1 year
1-5 years
Over 5 years

Please state your next symptom (physical or mental)

Symptom 3 Please consider how this symptom has been, over the last week, and score it by choosing a number (0 – no impact, 6 – maximum impact)

Selected Value: 0

For how long have you had Symptom 3?

0-4 weeks
4-12 weeks
3 months-1 year
1-5 years
Over 5 years

Please choose an activity (physical, social or mental) that is important for you, that your problem makes difficult or prevents you doing. *

Score how bad it has been in the last week (0 – no impact, 6 – maximum impact)

Selected Value: 0

Please choose another activity (physical, social or mental) that is important for you, that your problem makes difficult or prevents you doing.

Score how bad it has been in the last week (0 – no impact, 6 – maximum impact)

Selected Value: 0

Please rate your general feeling of well-being during last week (0 – no impact, 6 – maximum impact)

Selected Value: 0

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