Consultation Paper For Beauty Therapy Form PDF Details

The Beauty Therapy Form (BTF) consultation paper sets out the proposed steps to develop a new BTF that will replace the current Form. The Department of Education and Training is seeking comment on the proposed content of the new form. This paper provides an overview of the key aspects of the proposed BTF, including its purpose, structure, and key elements. It also discusses how the new form will be aligned with other national qualifications frameworks. Feedback is invited from stakeholders on all aspects of the proposed BTF. Submissions can be made via email or online survey until Friday 15 September 2017.

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Form NameConsultation Paper For Beauty Therapy Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesconsultation cards beauty therapy, beauty salon consultation form, consultation form template word, 4700 form medical

Form Preview Example

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

No

│

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Diabetes?

Yes

No

│

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

When did symptoms start (date):

 

 

 

 

 

 

 

 

High Blood Pressure?

Yes

No

│

Yes

No

 

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

Heart Disease?

Yes

No

│

Yes

No

 

Osteoporosis?

Yes

No

│

Yes

No

 

Have you had these symptoms before? □Yes

□No

 

 

 

 

Osteoarthritis?

Yes

No

│

Yes

No

 

How did symptoms start?

 

 

 

 

 

 

 

 

 

 

Rheumatoid arthritis?

Yes

No

│

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Neurologic dz (MS, Parkinsons)?

Yes

No

│

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Symptoms are?

□Constant

 

□Come/Go

 

□Only with Activity

Ulcers / GERD / Acid Reflux?

Yes

No

│

Yes

No

 

Symptoms are?

□Getting worse

□Not Changing

□Getting Better

Kidney / Liver Disease?

Yes

No

│

Yes

No

 

Prior Surgeries:

Yes

No

│

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fever / chills / sweats?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List any drug or latex allergies you are aware of:

 

 

 

□None

Unexplained weight change (>10lbs)?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Numbness or tingling?

 

Yes

No

 

 

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

 

 

Bowel / bladder incontinence?

 

Yes

No

 

 

□None

Difficulty sleeping due to pain?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unexplained Falls/Decreased balance?

Yes

No

 

 

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?

 

NA

Yes

No

 

Often bothered by feeling down, depressed, or hopeless?

Yes

No

 

(aka: “living will”)

Information is available at front desk.

 

 

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

Under physical / emotional abuse?

 

 

 

Yes

No

 

□Communication

□Vision

 

 

□None

 

 

 

 

 

Dietary or Nutritional Concerns?

 

 

 

Yes

No

 

□Speech

 

 

□Hearing

 

 

□Other:

 

 

 

 

 

 

Do you use tobacco products?

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

0

1

2

3

 

4

5

6

 

7

8

9

10

 

 

 

 

 

 

 

 

 

 

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: / / / /

 

 

 

 

 

 

0

1

2

3

 

4

5

6

 

7

8

9

10

 

 

 

 

 

 

 

 

 

 

Other Pain: - - - -

 

 

 

 

 

 

No pain

 

 

 

 

 

 

 

 

 

 

Worst pain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Imaginable

 

 

 

 

 

 

 

 

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

 

 

 

Therapist Notes:

 

 

 

 

 

 

_________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0

1

2

3

 

4

5

6

 

7

8

9

10

 

 

 

 

 

 

 

 

 

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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