treatment questionnaire notes
The Chiropractic Treatment Questionnaire is designed to provide an overview of the client’s current status, including ongoing improvements and any barriers to recovery that exist.
Please note that all questions must be answered for the questionnaire to be accepted. Please use block letters and attach any information that may be relevant.
What do you need to do
The TAC will forward this questionnaire to you for completion and return within one week.
What the TAC will do
The completed questionnaire will be reviewed by the TAC, following which we will write to you and the client advising of the outcome. A fee will be payable for the submission of a completed questionnaire. The applicable item no. is QU0050.
Where to send completed forms
Send completed questionnaires to:
Transport Accident Commission, GPO Box 2751, MELBOURNE Vic 3220,or fax the questionnaire to the TAC.
Incomplete or illegible questionnaires will be returned and payment will be withheld pending submission of a suitably completed questionnaire.
1. Work status
Pre accident work
Outline the client’s pre accident work, stating 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. Clinical assessment
2a. Diagnosis
Provide a definitive diagnosis determined by your assessment of the client, eg. ‘supraspinatus tear right shoulder’, or ‘left posterolateral protrusion at L4/5 intervertebral disc compromising nerve root’. Using a symptom to define the diagnosis is not acceptable.
2b. Clinical assessment related to the accident injuries include relevant investigation findings
State the current symptoms related to the accident. Specific measurable findings, eg. observed functional limitations, neurological examination and palpation findings. Include details of any relevant investigations that have been conducted, eg. radiology.
3. Chiropractic treatment details
Provide an outline of current strategies being used in the management of the client’s condition.
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. These will directly relate to your activity goals of treatment. State the activity goals of your treatment with estimated timeframes 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 6-1-06’.
5. 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). It should be recorded how these have changed over time and how they are influenced by chiropractic management.
6. Rehabilitation/maintenance
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.
6a. 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, eg. psychologist (requires GP referral), musculoskeletal physician, multidisciplinary pain management program, or the name of the chiropractor you are seeking a second opinion from.
6b. What self management strategies has the client been instructed in? List and include details of home management plan
Self management includes client education and strategies, eg. walking program, unsupervised hydrotherapy, a home exercise program, relaxation, joint protection/energy conservation techniques, pacing of activities. Include details of the client’s home management plan, including an outline of their exercise program.
6c/d. Have you explained to the client the importance of participation in the management of their condition?
Advise if the client has been educated regarding their condition and the likely outcome of treatment. Indicate whether they are aware of their role and compliant in the management of their condition?
7. Prognosis
7a. Is the client likely to fully recover?
State whether you believe it is likely that the client will return to their pre accident level of functioning.
Does the client understand their prognosis?
Have you discussed the client’s likely outcome with them? If they are unlikely to fully recover, are they aware of their prognosis?
7b. Does it appear that there are barriers to recovery other than natural progress of the known pathology?
If the client’s progress has been slower than anticipated, have you identified any factors, eg. psychosocial factors, which may be influencing the clinical course of their recovery?
The following questions should be answered if you feel you are able to comment. You are not required to complete this section if you do not feel qualified to comment on these issues, but the TAC assumes that you would refer the client to someone who is capable of assisting with these issues.
Non accident related pathology
Indicate if there are any ‘red flags’, eg. Cauda equina or neurological signs. Does the client have any physical problems/symptoms that will prevent full recovery? Comment on whether the client has been referred to a GP or specialist.
Psychological issues
Psychological issues that may have been identified include depression, anxiety, fear of increased pain with activity/work, low mood and/or irritability.
Problems with compliance
These may include poor compliance with self management program or poor attendance at therapy. Lack of motivation may also be a relevant factor.
Compensation/litigation issues
Is there any litigation pending or a decreased financial incentive to return to work? Are there current disputes that may be hindering progress?
Psychosocial issues
Behavioural issues that may have been identified include increased alcohol or drug consumption, practitioner dependence and/or significant decrease in activity level.
Adverse environmental factors
Does the client have an unsupportive work environment or home situation?
Pre existing problems
Indicate if there are any pre existing problems that impact on the current situation, eg. pre morbid degenerative spondylolisthesis, previous WorkCover claim for back injury.
Other issues
Provide details of any other issues that you believe may be relevant and outline the level of restriction you believe these will cause.
8. Proposed chiropractic management
Proposed further management
Provide details regarding number of services being requested and time-frame for ongoing treatment.
9. Future review process
9a. 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.
9b. Anticipated date for cessation of chiropractic management
Provide an estimate of when the client is likely to be discharged from chiropractic management.
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