Post Op Form

Instructions for completing this form:

This form is only for patients who have had surgery or an injection. If the patient has not had a procedure, please advise them to contact VitalityHealth regarding the process for authorising further sessions. Please only complete this form if all authorised sessions have been used. No further treatment should take place until VitalityHealth has given written authorisation to do so. Unauthorised treatment may not be covered under the patient’s policy. Please complete all sections of the form/ Please provide as much detail as possible to avoid delays in processing this form.

Date:

Patient’s policy no.:

Patient’s full name:

Patient’s date of birth:

Patient’s email address:

Patient’s postcode:

Clinic name:

Clinic telephone no.:

Clinic email:

Name of treating physiotherapist:

Treating physiotherapist’s HCPC no.:

Date of surgery/injection:

Procedure undertaken:

Affected side:

Left
Right
Both
Central

Physiotherapy Assessment Date:

Date of last attended physiotherapy session:

Total number of sessions attended to date, since procedure, including assessment appointment

Finding 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:

Please state the movement and provide the muscle strength as per the Oxford Scale

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 state the movement and provide the muscle strength as per the Oxford Scale

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:

Is the patient progressing as expected in line with clinical guidelines?

If not, please tell us why, including details of any underlying complications or medical issues which may be delaying recovery:

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 Patient Privacy Notice.