/ chiropractic:
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. Chiropractic treatment details

Please provide details of current chiropractic management

4. List current activity/functional limitations and related goals

Current activity/functional limitations / Short term activity goals
include Activities of Daily Living (ADLs) / 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: / Maintenance / Rehabilitation / Unsure

a. Does your diagnosis and/or management need to be reviewed? Yes No If yes, who have you chosen to review the client?

Another chiropractor / Other health professional
Name / 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

7. Prognosis

a. Is the client likely to recover? / Yes / No / Does the client understand their prognosis? / Yes / No
b. Does it appear that there are barriers to recovery other than natural progress of the known pathology? / Yes / No

If you feel qualified to comment, indicate what barriers you think exist?

Non accident-related pathology / Yes / No / Psychological issues / Yes / No / Compensation/litigation issues / Yes / No
Problems with compliance / Yes / No / Psychosocial issues / Yes / No / Other 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 chiropractic management, explain your treatment modality and treatment goals

Proposed treatment plan from today’s date

Total number of services / over / weeks from / // / to / //

9. Future review process

a. Date for review to consider referral to another health professional / //
b. Anticipated date for cessation of chiropractic management / //

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.


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