IndexFysioDelft - wie zijn wijBereikbaarheid en RouteTarieven en VoorwaardenDisclaimerInformatie Afspraak verzettenEnglishClaudicatioNetEnqueteVragenlijstenFoldersFysio Fit ScanHydrotherapieOuderen Fysio Fit - MBVOValpreventieZorgverzekeringOverige informatie en organisatiesGeriatrie Fysiotherapie  Privacyverklaring

English

                                                                                                            

Located near the TU-Delft ( 200 metres from the library ) The practice has excellent possibilities to help you if you need a Physiotherapist.  We have contacts with IPS ( International Insurance Passport for Students ) and almost any health insurance company in the Netherlands. Please contact the Physiotherapist for your compensation.

                      

The  Physiotherapist :

- Has contracts with several Dutch Health Insurance Companies ( ask your insurance company or the Physiotherapist ).

- Has regular communication between therapist and referring Consultant or your General Practitioner  

- Is registered at the Royal Dutch Institute of Physiotherapist ( KNGF ) and Law-BIG of the Dutch Ministry of Ministry of Health, Welfare and Sport.

- Has professional development by education.

 

Treatment possibilities :

- Exercise programs after Hip and Knee Orthopaedic surgery

- Manipulation and mobilization techniques

- Electrotherapy

- Massage therapy

- Excercises for at home

- Fall prevention test

- Physio Fit Scan

- Intermittent Claudication

- Rehabilitation programme Active Rehab

- Physio Fitness for elderly people

- Hydrotherapy Physiotherapy in water

 

Physiotherapy treatment sessions will last aprox 20 minutes.

Home visits are arranged for house-bound patients ( only after medical indication of the General Practitioner or specialist ).

Do you have any questions, just call +31 (0)15-2560130.

 
Do you want to make an appointment  ?
read the Practice Information (House Rules, Claims), Privacy Statement, Rates and Terms inadvance, before you fill in the questionnaire.  
 
 
 
 
 
 
 
 

 

Intital(s) and Surname*:
Date of Birth*:
Gender:
Address and house no*:
ZIP code and place of residence*:
Phone nr*:
E-mail*:
BSN ( Dutch Government Number ):
 
If you have a GP in Delft, please fill in. If not, please fill in "DTF" (Direct Acces Physiotherapy).
Name general practitioner ( GP):
We ask that you answer the following questions so that we can assess whether your complaints are indicative of Physical Therapy.
Can you briefly describe what complaint(s) you have ?:
How long do you have these complaints ?:
How is the course of these complaints ?:
Do you have an idea why and how the complaints occurred?:
Your physical complaints affect activities and movements that you do every day and are difficult to avoid. For everyone the consequences of physical are different. Every person will like to see certain activities and movements improve as a result of the treatment. Below are a number of activities and movements that could take a lot of effort to perform because of your complaints. Try to identify the problems that have caused you problem(s) during the past week. Check the bullet in front of this activity. We ask you to mark those problems that YOU ARE VERY IMPORTANT and that you would prefer to see CHANGE IN THE NEXT MONTHS. Please choose a maximum of 3 activities.
Patient Specific Complaints questionnaire: Laying in bed
Turn over in bed
Getting out of bed
Get up from a chair
Sit down on a chair
Sit for a long time
Get in / out of the car
Drive a car or bus
Cycle ( bike )
Standing
Standing for a long time
Light work in and around the house
Heavy work in and around the house
Walking at home ( inside )
Hiking
Running
Carrying an object
Pick something up from the ground
Lifting
Visiting family friends or relatives
Going out
Sexual activities
Performing work
Performing hobbies
Performing household activities
Sporting
Traveling
Other activities (please enter below)
other activities:
What activities do these complaints interfere to? (think of work, household, sports, hobby, etc.):
Due to your recovery, it is important that you, together with your therapist, also contribute to your therapy.
What do you expect from your Physical Therapist, what are your goals. And what could you do to participate?:
Have you had Physiotherapy before for these complaints ?:
Have you been to the general practitioner (GP) or specialist for these complaints? :
Do you use pain medication, corticosteroids (anti-inflammatory drugs) or other medicines?:
If Yes, what medicines do you use?:
Do you currently experience (much) stress ?:
 
Neurological questions (if applicable)
Do you have tingling in (parts of) your body ?:
Do you suddenly lose strenght in (parts of) your body ?:
Do you have a loss of / deaf feeling in (parts of) your body ?:
 
Physical load questions
Are you familiar with heart, vascular or lung problems ?:
Do you have pain or a stressful feeling on the chest at rest or in physical exercise ?:
Did a doctor tell you that your blood pressure is too high ?:
Space for questions or comments that may be of interest to Physical Therapy, or which you would like to discuss during your intake:
 
Permission and agreement
It is important that your GP or healthcare provider is aware of your health and therefore we would like to ask you for permission to inform your GP or referrer about your visit to the therapist, your complaints and recovery *
Contact with the GP or referrer:
* This questionnaire will be used for your privacy only by your therapist and will be sent to your GP or referrer only with your consent and will not be used for other purposes. If you give permission to inform the GP or referrer, the form will be discussed with you first.
 
National Database Physical Therapy (LDF)
The National Database Physical Therapy (LDF) is an initiative of the Royal Netherlands Society for Physiotherapy (KNGF). In this database we collect anonymous quality information from physiotherapeutic care and information on physiotherapy practice. Physiotherapists can use the information collected to monitor and improve the quality of their services themselves. No personal data will be sent.
 
By providing anonymous data to the LDF, you help the Physiotherapist to improve his quality:
 
Customer satisfaction survey
Do you agree to receive an e-mail to participate in a customer satisfaction survey at the end of your treatment series?:
 
Practice Information (House Rules, Claims), Privacy Statement, Rates and Terms
During the intake interview, a number of administrative data are recorded, such as creating an Electronic Patient Dossier (EPD), drafting the treatment agreement including treatment goals, your wishes and possibilities. In addition, you agree to the privacy statement and practice info about house rules, treatment, rates and terms. During the intake, you are asked to sign these forms in practice. Click on the logos below to read them in advance.
I have read the Practice Information (House Rules, Claims), Privacy Statement, Rates and Terms:
 
I agree the Practice Information (House Rules, Claims), Privacy Statement, Rates and Terms*:

and