📋 ConchyMan's Tele-Rehabilitation's Consent Form & Physiotherapy Evaluation File

← Back to Main Page

ConchyMan Tele-Rehabilitation

Patient Consent Form

CONSENT

Patient Information

Date

Time

Consultation ID

Patient Name

Age

Sex Select Male Female Other

Payment Transaction/Receipt Number

Session Start Time

Session End Time

Therapist Name Select Therapist Dr Naium Uddin (PT) Dr Manju (PT) Dr Sanjana (PT) Dr Masum Parvag (PT) Dr (PT)

Therapist Authorization

Therapist Password

Incorrect password. Please try again.

Tele-Rehabilitation Consent Form

Patient Details

Date:

-

Time:

-

Consultation ID:

-

Patient Name:

-

Age:

-

Sex:

-

Transaction No.:

-

Session Time:

-

Therapist:

-

Purpose of Tele-Rehabilitation

This consent form is for tele-rehabilitation services provided by ConchyMan. Tele-rehabilitation involves the delivery of rehabilitation services at a distance using telecommunications technology.

Treatment Details

The treatment will involve:

• Remote assessment of your condition through video/audio communication
• Personalized exercise programs demonstrated and monitored remotely
• Progress evaluation and modification of treatment plans
• Education about your condition and self-management strategies
• Regular communication with your therapist between sessions

Risks and Benefits

Potential benefits:

• Increased access to care without traveling
• More flexible scheduling options
• Continuity of care regardless of location
• Reduced exposure to infectious diseases
• Greater convenience and time savings

Potential risks and limitations:

• Technology failures may interrupt sessions
• Privacy and security concerns with digital communication
• Limited physical assessment capabilities
• Possibility of miscommunication without in-person contact
• Not all conditions may be appropriate for tele-rehabilitation

Informed Consent

I confirm that I have been given all necessary information about the tele-rehabilitation services and have had the opportunity to ask questions about the procedure, which have been answered to my satisfaction.

Alternatives

I understand that alternative treatments are available, including traditional in-person rehabilitation services. My therapist has discussed with me the risks and benefits of these alternatives.

Right to Refuse

I understand that I have the right to refuse treatment or to withdraw my consent at any time without penalty or compromise to future care.

Confidentiality and Information Sharing

I authorize ConchyMan to release necessary information to other healthcare professionals involved in my care, including my referring physician or primary care provider, as needed for my treatment.

I understand that my information will be handled according to privacy regulations, but acknowledge that electronic communication carries inherent risks to privacy.

Technical Requirements and Responsibilities

I understand that I am responsible for:

• Obtaining and maintaining appropriate technology (computer, tablet, or smartphone)
• Ensuring a stable internet connection
• Creating a private, well-lit space for sessions
• Having necessary assistive devices available during sessions
• Notifying my therapist if I experience technical difficulties

Limitations of Liability

I understand that ConchyMan and its therapists are not liable for:

• Technical failures beyond our control
• Interruptions in service due to internet or power outages
• Privacy breaches that occur due to factors outside our reasonable control

---

Privacy Policy | Disclaimer | Terms & Conditions | Refund & Cancellation Policy | Copyright Policy | Cookie Policy

Agreement

By checking the box below, I confirm that:

• I have read and understood the information provided
• I have had the opportunity to ask questions and received satisfactory answers
• I voluntarily consent to receive tele-rehabilitation services
• I understand the potential risks and benefits
• I am aware of alternative treatment options

I agree to the terms outlined above

Patient Signature (Type Full Name)

Date of Signature

Witness Name (if applicable)

PHYSIOTHERAPY EVALUATION FORM

Patient Name:

Age:

Occupation:

Address:

Gender:

Male Female

Referred By:

Phone Number:

Registration Number:

Patient Type:

IP OP

MEDICAL HISTORY

Civil Status:

Chief Complaints:

Diagnosis:

Past Medical History:

Personal History:

Family History:

Socioeconomic History:

SYMPTOMS HISTORY

Side:

Right Left Bilateral

Onset:

Site:

Duration:

Symptoms Details:

PAIN EVALUATION

Visual Analog Scale (0-10):

Pain Characteristics:

Pain Intensifiers:

Pain Relievers:

VITAL SIGNS

Temperature (°F):

Heart Rate (bpm):

Blood Pressure (mmHg):

Respiratory Rate (/min):

II. OBJECTIVE EXAMINATION

ON OBSERVATION

Built:

Wasting:

Oedema:

Any bandages, Scars:

Attitude of the Limbs:

Type of gait:

Bony contours:

Deformities:

ON PALPATION

Tenderness:

D/F tissue tension and texture:

Spasm:

Type of Skin:

Scar:

Swelling:

Crepitus, Abnormal sounds:

RANGE OF MOTION (ROM)

UPPER LIMB

JOINT	MOVEMENT	ACTIVE		PASSIVE		END FEEL
		RT	LT	RT	LT
SHOULDER	Flexion
	Extension
	Abduction
	Adduction
	Medial Rotation
	Lateral Rotation
	LIMITATION:

LOWER LIMB

JOINT	MOVEMENT	ACTIVE		PASSIVE		END FEEL
		RT	LT	RT	LT
HIP	Flexion
	Extension
	Abduction
	Adduction
	Medial Rotation
	Lateral Rotation
	LIMITATION:

MANUAL MUSCLE TESTING (MMT)

UPPER LIMB

MUSCLES	RT	LT
SHOULDER
Flexors
Extensors
Abductors
External Rotators

REFLEXES

REFLEX	LEFT	RIGHT
SUPERFICIAL
Abdominal
Plantar
DEEP
Biceps
Brachioradialis
Triceps
Knee
Ankle

MUSCLE GIRTH (cm)

AREA	RIGHT	LEFT
Arm
Forearm
Thigh
Calf

LIMB LENGTH DISCREPANCIES (cm)

SIDE	RIGHT	LEFT
True
Apparent

SENSORY ASSESSMENT

Dermatomes:

Myotomes:

FUNCTIONAL ASSESSMENT (FIM)

Evaluation 1: Self Care

Item 1. Food
Item 2. Care of appearance
Item 3. Hygiene
Item 4. Dressing upper body
Item 5. Dressing lower body

GAIT ANALYSIS

Stance Phase:

Base Width:

Swing Phase:

Cadence:

Step Length:

Stride Length:

Other:

BALANCE

Static

Sitting (With eyes open & closed):

Standing (With eyes open & closed):

Tandem Standing (With eyes open & closed):

Single Leg Standing:

Dynamic

Walking (Straight Line):

Turning Around:

Stepping Over Obstacles:

Head Turning:

SPECIAL TESTS

Upper Limb:

Lower Limb:

ASSESSMENT AND PLAN

Clinical Impression:

Treatment Plan:

Short & Long Term Goals:

Date:

Therapist Signature

ConchyMan Tele-Rehabilitation Services | Protected Health Information | © 2025

← Back to Main Page

Related Service: ConchyMan's Tele-Rehabilitation Services