OSTEOPATHY:
TREATMENT QUESTIONNAIRE
Privacy
The TAC will retain the information provided and may use or disclose it
to make further inquiries or assist in the ongoing management of the
claim or any claim for common law damages. The TAC may also be
required by law to disclose this information.
Without this information, the TAC may be unable to determine
entitlements or assess whether treatment is reasonable and may not be
able to approve further benefits and treatment. If you require further
information about our privacy policy, please call the TAC on
1300 654 329 or visit our website at www.tac.vic.gov.au
Please refer to the notes for assistance in completing this form
Client details
Client name
Claim number
Date of birth
Client occupation
Date of last GP review
/
/
Date of accident
/
/
/
/
1. Work status
Pre-accident work status
Number of hours worked per week
Current work status
Number of hours worked per week
2. Clinical assessment
a. Diagnosis
b. Clinical assessment related to the accident injuries, include relevant investigation findings
3. Osteopathy treatment details
Provide details of current osteopathy management
PO Box 2751
MELBOURNE VIC 3001
Telephone 1300 654 329
STD Toll Free 1800 332 556
DX 216079 Geelong
www.tac.vic.gov.au
ABN 22 033 947 623
OSF6 03/13
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OSTEOPATHY:
TREATMENT QUESTIONNAIRE
4. List current activity/functional limitations and related goals
Current activity/functional limitations
Short term activity goals
include ADL and work/travel goals
Estimated date of
achievement
1.
/
/
2.
/
/
3.
/
/
4.
/
/
5. Outcome measures
Outcome measure, assessment score and date administered
Outcome measure, assessment score and date administered
Date
/
/
Score
Date
/
/
Score
Date
/
/
Score
Date
/
/
Score
Date
/
/
Score
Date
/
/
Score
Date
/
/
Score
Date
/
/
Score
6. Rehabilitation/maintenance
Do your outcome measures suggest the client is in:
a. Does your diagnosis and/or management need to be reviewed?
Maintenance
Yes
Rehabilitation
Unsure
No If yes, who have you chosen to review the client?
Another osteopath
Name
Other health professional
Name
Telephone number
Telephone number
Type of specialist
b. What self-management strategies has the client been instructed in? List and include details of home management plan
c. Have you explained to the client the importance of participation in the management of his/her condition?
Yes
No
d. Is the client compliant with his/her self management strategies?
Yes
No
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OSTEOPATHY:
TREATMENT QUESTIONNAIRE
7. Prognosis
a. Is the client likely to recover?
Yes
No
Does the client understand their prognosis?
b. Does it appear that there are barriers to recovery other than natural progress of the known pathology?
If you feel qualified to comment, indicate what barriers you think exist?
Non accident related
Yes
No
Psychological issues
pathology
Yes
No
Yes
No
Yes
No
Compensation/litigation
issues
Yes
No
Other issues
Yes
No
Problems with compliance
Yes
No
Psychosocial issues
Yes
No
Adverse environment factors
Yes
No
Pre existing problems
Yes
No
Provide relevant details, including likely level of restrictions these factors will cause
8. Proposed osteopathy management, explain your treatment modality and treatment goals
Proposed treatment plan from today’s date
Total number of services
over
weeks from
/
/
a. Date for review to consider referral to another health professional
/
/
b. Anticipated date for cessation of ‘in-rooms’ osteopathy management
/
/
to
/
/
9. Future review process
Provider details
Provider name, address and phone no. Use practice stamp where
possible
Signature
Days/hours available
Telephone number
Date
/
/
Authorisation
I,
of
hereby authorise you to supply the TAC with information requested on this form and to discuss the contents of this form, and any ongoing issues
regarding my treatment, with officers or representatives of the TAC.
Signature of client, parent or guardian
Print name
Date
/
/
All questions must be answered for this plan to be considered. Please use block letters and attach any information that may be relevant.
OSF6 03/13
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