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CAREGIVER QUESTIONARE
NEW PATIENT
1001
Recovery journey ID number
2001
Patient ID number
3001
Caregiver ID number
Patient’s Questionnaire
Impaired ability to perform an action
Rate of Pain
Rate
of Frequency
Rate of
Intensity
Duration
(months)
What is the reason for coming to treatment (symptoms)?
.1
Rate the following parameters from 1 the lowest to 10 the highest. If not applicable, select "not applicable"
Main Reason
Other
If relevant to the symptoms, rate the following parameters
.2
Rate the following parameters from 1 the lowest to 10 the highest. If not applicable, select "not applicable"
-
Is there a western medical diagnosis?
.3
Is the client receiving medication?
Are there side effects?
Did the client receive any other treatments
Were tests done? (blood, blood pressure, radiology, etc.)
If so, please note:
Did the client visit the emergency room for these reasons?
If so, please note:
Was the client hospitalized for these reasons?
Was surgical intervention recommended?
.4
Does the reason for coming have an effect on:
Rate the following parameters from 1 the lowest to 10 the highest. If not applicable, select "not applicable"
Caregivers Conclusions:
.5
Diagnosis
.6
What treatment methods will be used?
According to which therapeutic principle?
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