Patient Registration Form

Patient Informaton

Company Health of

Title Field

Patient Name

Address

Address Line 1

City

State / Province / Region

Postal Code

Date of Birth

Gender

Phone Number

Phone Number (additional number)

Insurance Details (if applicable)

Name of Insurance Company

Insurance Membership/Authorisation Number

Payment Details

Self Pay

A cancellation fee of £20 will be charged for non-attendance or for cancellations made with less than 24 hours’ notice.

Medical Insurance/Solicitor or Occupational Health Dept/Work Place

A cancellation fee of £20 will be charged for non-attendance or cancellations made with less than 24 hours’ notice. If your insurance company, solicitor, or Occupational Health/Work does not cover this fee, you may lose a session.

Please Sign – Blunsdon Abbey Physiotherapy (BAP) Data Protection and Confidentiality Statement

Clear Signature

Blunsdon Abbey Physiotherapy (BAP) adheres to current data protection laws and medical confidentiality guidelines. By signing this form, you confirm that you give full consent for BAP to process and retain your personal information, in accordance with the General Data Protection Regulation (GDPR) 2018, for the period required by law.

Medical Information

To enable your Physiotherapist to fully assess your condition, please answer the following questions:

Do you suffer from any of the following conditions:

	Yes	No
Osteoarthritis or Rheumatoid arthritis?	YesOsteoarthritis or Rheumatoid arthritis? Yes	NoOsteoarthritis or Rheumatoid arthritis? No
Osteoporosis?	YesOsteoporosis? Yes	NoOsteoporosis? No
Skin infection, open wound or eczema or psoriasis?	YesSkin infection, open wound or eczema or psoriasis? Yes	NoSkin infection, open wound or eczema or psoriasis? No
Areas of altered or decreased sensation, such as pins and needles or numbness?	YesAreas of altered or decreased sensation, such as pins and needles or numbness? Yes	NoAreas of altered or decreased sensation, such as pins and needles or numbness? No
Diabetes?	YesDiabetes? Yes	NoDiabetes? No
Epilepsy, fitting, blackouts or fainting?	YesEpilepsy, fitting, blackouts or fainting? Yes	NoEpilepsy, fitting, blackouts or fainting? No
Circulatory problems, such as embolus or high/low blood pressure?	YesCirculatory problems, such as embolus or high/low blood pressure? Yes	NoCirculatory problems, such as embolus or high/low blood pressure? No
Cardiovascular problems, such as heart failure or angina?	YesCardiovascular problems, such as heart failure or angina? Yes	NoCardiovascular problems, such as heart failure or angina? No
Lung problems?	YesLung problems? Yes	NoLung problems? No
Malignancy, tumours or any unusual lumps?	YesMalignancy, tumours or any unusual lumps? Yes	NoMalignancy, tumours or any unusual lumps? No

Please answer “yes” or “no” for each question

Do you have any other medical conditions?

Do you Have:

	Yes	No
Any metallic or electrical implants, such as a pacemaker or hearing aid?	YesAny metallic or electrical implants, such as a pacemaker or hearing aid? Yes	NoAny metallic or electrical implants, such as a pacemaker or hearing aid? No
Any allergies	YesAny allergies Yes	NoAny allergies No

Please provide any allergies in the box below

Please enter allergies if ticked "yes"

Have you:

	Yes	No
Had any recent or major operations?	YesHad any recent or major operations? Yes	NoHad any recent or major operations? No
Had any recent to major accidents	YesHad any recent to major accidents Yes	NoHad any recent to major accidents No
Noticed any significant unexplained weight change recently?	YesNoticed any significant unexplained weight change recently? Yes	NoNoticed any significant unexplained weight change recently? No
Ever taken steroids or anticoagulant therapy?	YesEver taken steroids or anticoagulant therapy? Yes	NoEver taken steroids or anticoagulant therapy? No

If you answered “yes” to any of the question’s above, please provide further information in the box below

If the answer to any of the above questions is "yes", please provide details below:

Are you:

	Yes	No	Not applicable
Pregnant or is there a possibility that you could be pregnant?	YesPregnant or is there a possibility that you could be pregnant? Yes	NoPregnant or is there a possibility that you could be pregnant? No	Not applicablePregnant or is there a possibility that you could be pregnant? Not applicable
Are you currently taking any medication?	YesAre you currently taking any medication? Yes	NoAre you currently taking any medication? No	Not applicableAre you currently taking any medication? Not applicable
A smoker or ex-smoker or non-smoker?	YesA smoker or ex-smoker or non-smoker? Yes	NoA smoker or ex-smoker or non-smoker? No	Not applicableA smoker or ex-smoker or non-smoker? Not applicable

If the answer to any of the above questions is "yes", please provide details below:

Blunsdon Abbey Physiotherapy (BAP) Communication Consent

Our physiotherapists may wish to communicate with your GP/Consultant/Occupational Health Dept. during the period of treatment. May we have your permission to do this?

To make a thorough assessment and determine the most appropriate treatment, you may be required to remove certain items of clothing. Please note that both the assessment and treatment may involve physical contact.

Signature

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