Consultation Paper For Beauty Therapy Form – Fill Out and Use This PDF

The Consultation Paper for Beauty Therapy form is a comprehensive document designed to gather essential medical history and supplemental data for individuals undergoing beauty therapy. It covers a wide range of information from ankle problem assessments to personal medical history, ensuring a safe and personalized treatment plan. If you're considering beauty therapy, make sure to fill out the Consultation Paper to help your therapist provide the best care tailored to your needs by clicking the button below.

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Consultation Paper For Beauty Therapy Form PDF Details

In the realm of healthcare and patient management, the completion and thorough analysis of medical forms, like the Consultation Paper For Beauty Therapy form, play a pivotal role in ensuring tailored and effective treatment strategies. Structured primarily for a comprehensive gathering of a patient's medical history and current health status, this document extensively covers various health aspects ranging from personal and family medical history, the specifics of any current symptoms—including their onset and characteristics—to detailed queries about past surgeries, medication intake, and lifestyle habits such as diet, exercise, and tobacco use. Furthermore, it delves into psychological well-being, checking for signs of depression or anxiety, and evaluates the physical functionality and pain levels through patient self-assessment tools like the Ankle Joint Functional Assessment Tool. The intricate design of the form, approved by the Office of The Surgeon General, serves to map out a meticulous medical landscape of the patient, aiding healthcare professionals, specifically within the fields of physical therapy and beauty therapy, to diagnose accurately and curate precise treatment protocols. Its use underlines the importance of a holistic approach in patient care, considering everything from basic health indicators to nuanced aspects of physical and emotional well-being.

Question	Answer
Form Name	Consultation Paper For Beauty Therapy Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	consultation cards beauty therapy, beauty salon consultation form, consultation form template word, 4700 form medical

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MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General

REPORT TITLE Physical Therapy Medical History Intake Form Ankle Problem

OTSG APPROVED (Date)

MOS/Occupation:

Medical History:

Self

│

Family

Duty Station/Unit:

Cancer?

Yes

│

Yes

Diabetes?

Yes

│

Yes

When did symptoms start (date):

High Blood Pressure?

Yes

│

Yes

Symptoms related to deployment? □Yes-Combat □Yes-NonCombat □No

Heart Disease?

Yes

│

Yes

Osteoporosis?

Yes

│

Yes

Have you had these symptoms before? □Yes

□No

Osteoarthritis?

Yes

│

Yes

How did symptoms start?

Rheumatoid arthritis?

Yes

│

Yes

Neurologic dz (MS, Parkinsons)?

Yes

│

Yes

Symptoms are?

□Constant

□Come/Go

□Only with Activity

Ulcers / GERD / Acid Reflux?

Yes

│

Yes

Symptoms are?

□Getting worse

□Not Changing

□Getting Better

Kidney / Liver Disease?

Yes

│

Yes

Prior Surgeries:

Yes

│

List any medications or dietary supplements your are taking:

Other:

In the past 3 months have you had or do you experience:

□None

Change in your general health?

Yes

Fever / chills / sweats?

Yes

List any drug or latex allergies you are aware of:

□None

Unexplained weight change (>10lbs)?

Yes

Numbness or tingling?

Yes

List Assistive Devices you use (crutches, braces, shoe inserts):

Bowel / bladder incontinence?

Yes

□None

Difficulty sleeping due to pain?

Yes

Unexplained Falls/Decreased balance?

Yes

Are you in the Personal Reliability Program (PRP)?

□Yes

□No

Are you currently/Do you have:

Have you completed advanced medical directives?

□Yes

□No

Pregnant / Potentially Pregnant / Nursing?

Yes

Often bothered by feeling down, depressed, or hopeless?

Yes

(aka: “living will”)

Information is available at front desk.

Often bothered by little interest or pleasure in doing things? Yes

Do you have difficulties with? (check all that apply)

Under physical / emotional abuse?

Yes

□Communication

□Vision

□None

Dietary or Nutritional Concerns?

Yes

□Speech

□Hearing

□Other:

Do you use tobacco products?

Yes

Mark an “X” on the lines below that best describes your response.

Indicate the location and

1. Which activity causes you the most pain / most trouble performing?

type of pain on the chart:

___________________________________________

Function: Rate your ability to perform the ABOVE activity.

Key:

Ache/Dull: ^ ^ ^ ^

_________________________________________________________

Sharp/Stabbing: x x x x

Numb / Tingling: o o o o

Unable to Perform

No restrictions

2. Pain at WORST: Rate your highest pain level in past 72 hrs.

Pins & Needles: · · · ·

Burning: = = = =

_________________________________________________________

Throbbing: / / / /

Other Pain: - - - -

No pain

Worst pain

Imaginable

3. Pain at BEST: Rate you lowest pain level in past 72 hrs.

Therapist Notes:

_________________________________________________________

No pain

Worst pain

Imaginable

4.Impact: How distressing is this condition to you?

_________________________________________________________

0	1	2	3	4	5	6	7	8	9	10
No problem									Devastating

PATIENT SIGNATURE / PREPARED BY:

DATE

DEPARTMENT/SERVICE/CLINIC

LRMC Physical Therapy

APO AE 09180 486-8263

PATIENTS IDENTIFICATION (For typed or written entries give: Name-last, first, middle; grade; rank; hospital or medical facility)

HISTORY/PHYSICAL

FLOW CHART

NAME (Last, First MI):
FMP / SSN (Sponsor):	/
GRADE or RANK:	DOB:
	(Patients, dd-mmm-yyyy)

OTHER/EXAMINATION

OR EXAMINATION

DIAGNOSTIC STUDIES

TREATMENT

OTHER (Specify)

DA	FORM	4700	MCEUH OP 370-R, APR 96(Rev)
	1 MAY 78		DA 4700 Master Rx Form, Updated 13-May-11

Ankle Joint Functional Assessment Tool (AJFAT)

Section 1: To be completed by patient	_______AD	______Non-Active Duty
Name:______________________________	Age:_______	Date:__________________
Occupation:_________________________	How long have you had ankle problems:_____________

Section 2: To be completed by patient

This questionnaire has been designed to give your therapist information as to how your ankle problems have affected your functional ability. Please answer every question by placing a check on the line that best describes your injured ankle compared with the non-injured side. Check only 1 answer for each question, choosing the answer that best describes your injured ankle. We realize you may feel that two of the statements may describe your condition, but please check only the line which most closely describes your current condition.

1.How would you describe the level of pain you experience in your ankle?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in amount to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

2.How would you describe any swelling in your ankle?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in amount to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

3.How would you describe the ability of your ankle when walking on uneven surfaces?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in ability to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

4.How would you describe the overall feeling of stability of your ankle?

_____Much less stable than the other ankle

_____Slightly less stable than the other ankle

_____Equal in stability to the other ankle

_____ Slightly more stable than the other ankle

_____ Much more stable than the other ankle

5.How would you describe the overall feeling of strength of your ankle?

_____Much less strong than the other ankle

_____Slightly less strong than the other ankle

_____Equal in strength to the other ankle

_____ Slightly stronger than the other ankle

_____ Much stronger than the other ankle

6.How would you describe your ankle’s ability when you descend stairs?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in amount to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

Ankle Joint Functional Assessment Tool, p. 2

Section 2 (con’t): To be completed by patient

7.How would you describe your ankle’s ability when you jog?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in amount to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

8.How would you describe your ankle’s ability to “cut,” or change directions, when running?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in amount to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

9.How would you describe the overall activity level of your ankle?

_____Much less than the other ankle

_____Slightly less than the other ankle

_____Equal in amount to the other ankle

_____ Slightly more than the other ankle

_____ Much more than the other ankle

10.Which statement best describes your ability to sense your ankle beginning to “roll over”?

_____Much later than the other ankle

_____Slightly later than the other ankle

_____At the same time as the other ankle

_____ Slightly sooner than the other ankle

_____ Much sooner than the other ankle

11.Compared with the other ankle, which statement best describes your ability to respond to your ankle beginning to “roll over”?

_____Much later than the other ankle

_____Slightly later than the other ankle

_____At the same time as the other ankle

_____ Slightly sooner than the other ankle

_____ Much sooner than the other ankle

12.Following a typical incident of your ankle “rolling,” which statement best describes the time required to return to activity?

_____ More than 2 days

_____ 1 to 2 days

_____ More than 1 hour and less than 1 day

_____ 15 minutes to 1 hour

_____ Almost immediately

Section 3: To be completed by physical therapist/provider
SCORE:___________ out of 48 possible points (higher better)	Initial	2 weeks	Discharge
Number of treatment sessions:________________	Gender:	Male	Female
Diagnosis/ICD-9 Code:_______________________

1Adapted from: Rozzi SL, et al. Balance Training for Persons With Functionally Unstable Ankles. JOSPT 1999; 29 (8): 478-486 [Prepared July 1999]

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Step no. 1 in filling in beauty therapy consultation forms

2. After this array of blank fields is done, go to type in the relevant details in all these - Do you have difficulties with, Which activity causes you the, Function Rate your ability to, No restrictions, Pain at WORST Rate your highest, No pain Worst pain Imaginable, Pain at BEST Rate you lowest pain, No pain Worst pain Imaginable, Indicate the location and type of, Key AcheDull SharpStabbing x x, Therapist Notes, Impact How distressing is this, No problem, Devastating, and PATIENT SIGNATURE PREPARED BY.

Tips to prepare beauty therapy consultation forms step 2

3. In this particular part, look at Ankle Joint Functional Assessment, Section To be completed by, Name Age Date, Occupation How long have you had, Section To be completed by patient, Much less than the other ankle, Much less than the other ankle, and This questionnaire has been. All of these are required to be filled in with utmost accuracy.

beauty therapy consultation forms completion process shown (portion 3)

4. To move onward, this form section involves typing in a couple of form blanks. These comprise of Much less than the other ankle, This questionnaire has been, Much less stable than the other, Much less strong than the other, and Much less than the other ankle, which are crucial to going forward with this particular process.

A way to complete beauty therapy consultation forms stage 4

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This questionnaire has been, Much less than the other ankle, and This questionnaire has been of beauty therapy consultation forms

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Consultation Paper For Beauty Therapy Form – Fill Out and Use This PDF

Consultation Paper For Beauty Therapy Form PDF Details

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