Form Template A4 Standard



Very Special KidsPhysiotherapy Management PlanGOLDCARE NUMBER ( CLIENT ID) GIVEN NAME FAMILY NAME DATE OF BIRTH SEX PHYSIOTHERAPIST CONTACT DETAILSName:Place of Work:Phone:Email:CURRENT PHYSIOTHERAPY GOALS123Examples –To maintain clear chestTo improve gross motor skills eg ball skills, running, jumpingTo improve walking abilityTo improve standing balanceTo improve sitting balanceTo improve crawlingTo improve moving on the floorTo practice standing transfersTo improve leg strengthTo increase muscle length and flexibilityTo increase general fitnessPositioningPreferred Positioning - SleepPreferred Positioning - DayEquipment - Please specify length of time used and amount of supervision requiredWheelchairSpecialised seating e.g. corner chair, tumbleform, gravity chair, high-low chair, gel chairStanding frameWalking frameMAIN METHOD OF MOBILITY – Please tick10813811482310036303421016000WalkingRolling10783023387100Crawling Wheelchair Very Special KidsPhysiotherapy Management PlanGOLDCARE NUMBER ( CLIENT ID) GIVEN NAME FAMILY NAME DATE OF BIRTH SEX SPLINTS – Please specify length of time worn and time of day/night usedSecond skinUpper limb splintLower limb splintRESPIRATORY CARE - Does your child have chest physiotherapy? Please tick.1000664799100Regularly 10006641661800When unwell 10088592413000NoDescribe your child’s normal respiratory secretionsOutline your child’s chest physiotherapy routine. (Please provide a copy of your child’s Complex Care Plan if you have one) Include positions for treatment, nebulisers, techniques, cough assist, suctionPlease sign this authorisation confirming the information given is current and any necessary changes have been endorsed and dated.Reviewed by family and signedDateSignatureDateSignatureReviewed By Staff MemberDateSignatureDesignationDateSignatureDesignation ................
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