OON Form

Instructions for completing this form:

Please only complete this form if all authorised sessions have been used. No further treatment should take place until IPRS Health has given written authorisation to proceed. Unauthorised treatment may not be covered under this patient’s policy. Please complete all sections of the form. The form should not be used for physio after surgery or an injection; please advise the patient to contact VitalityHealth if they require physio after a procedure. Please provide as much detail as possible to avoid delays in processing this form.

Date:

Patient’s Policy No.:

Has Vitality Health authorised treatment?

If yes, authorisation no.:

Patient’s full name*:

Patient’s date of birth*:

Clinic name*:

Clinic Telephone no.:

Clinic email:

Name of treating physiotherapist*:

Treating physiotherapist’s HCPC no.*:

Affected side*:

Left
Right
Both
Central

Approximate date of onset:

Provisional diagnosis:

Initial Assessment Date*:

Date of last attended session*:

Total number of sessions attended, including Initial Assessment*:

Findings at initial assessment

Pain scores /10*:

Please provide the best and worst pain score out of 10

Range of Movement*:

Please state the direction and the ROM as a percentage of normal

Muscle Strength /5*:

This could include any functional measurement reported or assessed, e.g. activity duration, distance or number of repetitions which can be achieved. Please provide the value, not just what you are measuring.

Functional Difficulty (%):

Please provide a functional task and state the percentage of normal function

Findings at last attended session

Pain scores /10*:

Please provide the best and worst pain score out of 10

Range of Movement*:

Please state the direction and the ROM as a percentage of normal

Muscle Strength /5*:

Please provide a functional marker and state the percentage of normal function

Functional Difficulty (%):

Please provide a functional task and state the percentage of normal function

Overall level of improvement (where 100% is fully recovered):

This must be as reported by the patient. 0% would be no improvement at all, 100% would be fully recovered. Please ask the patient to rate their current recovery on a scale of 0 to 100%.

Patient agreed treatment goals

Treatment modalities used to date:

Future Rehab Plans:

Number of additional sessions recommended:

Frequency of recommended sessions:

Justification for further treatment recommendations:

Any other relevant information*:

Projected Discharge Date:

Please note by submitting this form you are agreeing that you have consent to submit patient data, you understand that IPRS Health will store that data in order to process your submission and that you have read our Privacy Policy.