TREATMENT QUESTIONNAIRE notes / physiotherapy:
treatment notification plan notes
The Acupuncture: Treatment Questionnaire is designed to provide an overview of the client’s current status, includingongoing improvements and any barriers to recovery.
Please note that all questions must be answered for theTAC to accept this form. Please use block letters and attach any information that may be relevant.
Who can provide acupuncture services?
Acupuncture services can be provided by:
- registered medical practitioners
- chinese/oriental medicine practitioners who must be either registered in accordance with the Health Professions Registration Act 2005 or hold an endorsement for acupuncture granted by a National Registration Board (where required)
- other practitioners as listed above who must be endorsed to provide acupuncture services under section 28 of the Health Professions Registration Act 2005.
What the TAC will do
Your completed questionnaire will be reviewed by the TAC. We will then write to you and the client advising of the outcome. A fee is payable for the submission of a completed questionnaire. The item number is A650.
Where to send completed forms
Send completed questionnaires to:
Transport Accident Commission, GPO Box 2751, MELBOURNE VIC, 3001.
Incomplete or illegible questionnaires will be returned to you and payment will be withheld pending submission of a suitably completed questionnaire.
1. Work/functional status
Pre-accident work
Outline the client’s pre accident work, type of work, if they were employed full time, part time or casually, and the number of hours worked per week.
Current work status
State if the client has returned to work, the hours they are currently working and if the type of work is different from their pre-accident employment.
2. Specific anatomical site of accident injuries and clinical diagnosis
Provide the medical diagnosis which the client presents with and the working diagnosis of the condition you are treating.
3. Current reported symptoms and physical assessment findings
State the current symptoms related to the accident as the client describes them to you. Place symptoms in order of priority for your acupuncture treatment. Detail your measurable findings. For example,range of movement, neurological examination findings, muscle strength tests, palpation findings, specific musculo-skeletal tests, etc.
4. List current activity/functional limitations and related goals
Provide details of specific activity limitations that your client experiences as a result of the accident injuries. These will directly relate to your activity goals of treatment. State the activity goals of your treatment with estimated time-frames for achieving the goals. For example, ‘unable to walk around the shopping centre’, ‘to be able to walk around the shopping centre for 30 minutes by 06/03/2013.
5. Acupuncture treatment details
List the total number of acupuncture services provided to date, noting the frequency and also the date commenced.
6. Outcome measures
Functional disability questionnaires
Details of functional disability questionnaires should be included. Some frequently used questionnaires are available from the TAC website
Other measures may include recording the number of headaches over a time period, days off work or medication use (frequency and dosage). You should record how these have changed over time and how they are influenced by acupuncture management.
7. Rehabilitation/maintenance
7a. Do your outcome measures suggest the client is in maintenance, rehabilitation or are you unsure?
With reference to your subsequent outcome measures, indicate whether the client is in a rehabilitation or maintenance phase of management. State if you are unsure.
7b. Does your diagnosis and/or management need to be reviewed?
Review by another health professional should be initiated if you are unsure about your diagnosis and/or management. Indicate the name and type of specialist you are considering referral to, e.g. psychologist (requires GP referral), musculoskeletal physician, multidisciplinary pain management program, or the name of the chinese/oriental medicine practitioner you are seeking a second opinion from.
8. Proposed treatment plan
Provide details regarding number of additional services being requested and time-frame for ongoing treatment.
9. List the education and self management strategies to be implemented by client/carer
List the strategies and educational advice that you are going to implement and undertake to empower the client to self manage their condition, such as a specific home exercise program, a general fitness and walking program, relaxation and/or joint protection techniques. Client education may include advice given to the client about the diagnosis and prognosis of their condition and self-pacing principles.
10. Future review process
10a. Date of next measured therapy break
If acupuncture management is to continue, regular measured therapy breaks must be undertaken to justify ongoing intervention.
10b. Date for review to consider referral to another health professional
Referral to another health professional should be considered if the client is not progressing as expected.
10c. Anticipated date for cessation of acupuncture management
Provide an estimate of when the client is likely to be discharged from acupuncture management.
ACPF1n 07/12 / 60 Brougham Street
GEELONG VIC 3220
GPO Box 2751
MELBOURNE VIC 3001
Ausdoc DX 216079 Geelong / Telephone 1300 654 329
STD Toll Free 1800 332 556
ABN 22 033 947 623 /