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Doctor's Risk Screening

Assessment For Participation In
Chronic MSK Rehabilitation Program

Patient Surname
Please enter a valid patient surname

Patient Name
Please enter a valid patient name

Does the patient have an SA ID Number?
Please select an option

ID Number
Incorrect Value

Passport Number
Incorrect Value

Date of Birth
Please enter a valid date of birth

Gender
Incorrect Value

Medical Aid
Please select a Medical aid

Medical Aid Plan
please enter a valid medical aid plan

Medical Aid Number
please enter a valid medical aid number

Date of assessment
please enter a valid date

Medical History

Onset of Illness / Injury Date
Incorrect Value

Onset of Illness / Injury symptoms details
Incorrect Value

Is the patient taking any medication for their current condition/injury?

Yes NoIncorrect Value

Medication Comments
Incorrect Value

At the time of the assessment, is future surgery/intervention planned within the next 3 months?
Not yet selected No Yes Incorrect Value

Please specify
Incorrect Value

At the time of assessment has the patient undergone surgery/intervention within the las 3 months?
No yet completed No Yes Incorrect Value

Please indicate type of surgery/intervention
Incorrect Value

Relevant past medical history
Incorrect Value

Relevant family medical history
Incorrect Value

Co-Morbid diagnosis and General Health

Does the patient currently have , or have a history of, any of the following conditions?
Good General Health / No Comorbidities
Any Other Chronic illnesses
Back or neck problems (whiplash / Scoliosis / extra vertebrae)
Diabetes Mellitus
Epilepsy
Excessive bleeding after extractions, injury or surgical operations
Gastric Conditions (Hernias / diarrhea / hernias / Other)
Heart Condition (e.g. Angina / Congenital Disease / Rheumatic Fever / Pacemaker / Other)
High BP
High Cholesterol
History Of Thrombosis (varicose veins / circulatory problems etc)
Kidney or Bladder Disease
Liver Conditions (Jaundice / Hepatitis / Other)
Low BP
Malignant Disease (Cancer)
Osteoporosis or other diseases of the bones and joints
Over or under active Thyroid
Pregnant
Respiratory Condition (Asthma / TB / Bronchitis / Other lung diseases)
Rheumatoid Arthritis
Incorrect Value

Comments/differential diagnosis
Incorrect Value

Is the patient taking medication for a chronic/Co-morbid condition?

Yes NoIncorrect Value

please specify
Incorrect Value

Physical Assessment

Reported Symptoms
Incorrect Value

Physical assessment details
Incorrect Value

Red Flags

Does the patient present with red flags?

Yes NoIncorrect Value

Please specify
Age Of Onset Less Than 20 Or More Than 55 Years
High Fever, Chills Or Sudden Weight Loss
History Of Cancer
History Of Immunosuppression
Long Term Corticosteroid Use
Loss Of Control Of Bowel Or Bladder
None Identified
Pain Worsening At Night Irrespective Of Body Position
Recently experienced a fall (slipped on a surface/fell from a height) within the last 6 weeks
Recently involved in an MVA (within the last 6 weeks)
Saddle Anaesthesia (Numbness In Groin Area)
Severe Or Progressive Sensory Alteration Or Weakness In Lower Limbs (Foot Drop And Or Disturbed Gait)
Structural Deformity / Instability
Sudden Severe Back Pain With Abdominal Pain
Thoracic Pain
Vertebral Artery Insufficiency
Incorrect Value

Conclusion

Is the patient medically safe to continue participating in the rehab program?

Yes No Incorrect Value

Please provide further information
Incorrect Value

Please indicate plan of action
Incorrect Value

Assessing Doctor's Details

First Name
Incorrect Value

Last Name
Incorrect Value

Email
Incorrect Value

HPCSA No.
Incorrect Value

Practice No.
Incorrect Value

Incorrect Value

I confirm that I possess the necessary medical credentials and am duly qualified and authorized to complete this assessment, and that the information captured has been recorded by a licensed medical practitioner

Reference Number

REF-250251 Incorrect Value

Self Referral - Referral Status

Incorrect Value

Self Referral - Referral QA Status

Incorrect Value

Self Referral - Referral Source

Medical Aid Patient GP Specialist Employer InsuranceIncorrect Value

Self Referral - Referral Source Type

Direct (Word Of Mouth) Medical Aid Centre Contact Email WhatsApp From Review Social Media - Facebook Social Media - LinkedIn Youtube Other Medical Aid Call Centre Contact Medical Aid Whatsapp Medical Aid Email Medical Aid Website Medical Aid Facebook Medical Aid Other Social Media Network Practice Direct Patient Call Network Practice Direct Patient Whatsapp Network Practice Direct Patient Email Network Practice Website Network Practice Facebook Network Practice Other Social Media Network Practice Employer Marketing Workability Whatsapp Workability Email Workability Website Workability Facebook Workability Other Social Media From Gp From Patient Reviews Resilient Health PortalIncorrect Value

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021 518 1110

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Doctor's Risk Screening

Assessment For Participation In Chronic MSK Rehabilitation Program

Medical History

Co-Morbid diagnosis and General Health

Physical Assessment

Red Flags

Conclusion

Assessing Doctor's Details

Assessment For Participation In
Chronic MSK Rehabilitation Program