APPOINTMENT PREPARATION

Osteopathic Health information

  Precision Manual Osteopathy 1102 Ridgeway Ave.
Coquitlam, BC. V3J 1S9 604 440 5856 |
OSTEOPATHIC HEALTH INFORMATION
● Every detail you provide will help achieve your health goals and will remain confidential. Please bring this completed form to your first appointment. ● Please come to each appointment with a change of clothing. For women, a tank top and shorts or yoga type pants (comfortable pants). For men; a t-shirt and shorts or comfortable pants. This is for diagnosing purposes, it is ideal to palpate the skin without layers of clothing impeding. ● During the Initial Appointment, an assessment will be performed. We will then discuss the findings with you and develop an appropriate treatment plan based on individual needs.
Name: _________________________________________________ Date: _________________ Date of Birth (dd/mm/yy): ____________________ Age: _______ Gender: ________________ Care card no.: ________________ Address: _____________________________________________________________________ Postal Code: ____________ Email address: _________________________________________ Phone: ______________________ Occupation: _________________________
Family Doctor: ____________________________________ Phone: ______________
What is the best way for us to contact you? __________________________________________
May we leave a telephone message at home or work? _________________________________
Would you like the receive our clinic email newsletter? _________________________________
How did you hear about this health practice? _________________________________________
Please list all other healthcare practitioners you receive care from, including your dentist:
1.________________________ 2. _____________________ 3. ________________________ __________________________ ________________________  ________________________
Present Conditions: Why have you come, what’s bothering you now? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Please list your primary health concerns, in order of importance:
1.__________________________________________________ Date of onset: _____________ 2.__________________________________________________ Date of onset: _____________ 3.__________________________________________________ Date of onset: _____________
Do you have any other health concerns? ____________________________________________
Please list any hospitalizations, surgeries (including dental), traumas (including emotional traumas) or major illnesses: 1.________________________________ Date Started: __________ Date Resolved:__________ 2.________________________________ Date Started: __________ Date Resolved:__________ 3.________________________________ Date Started: __________ Date Resolved:__________ 4.________________________________ Date Started: __________ Date Resolve: __________ 5.________________________________ Date Started: __________ Date Resolved: _________
Please list any medication you taking, including antacids, pain medications, and laxatives: 1._______________________________________ Date Started: __________ Dose: _________ 2._______________________________________ Date Started: __________ Dose: _________ 3._______________________________________ Date Started: __________ Dose: _________ 4._______________________________________ Date Started: __________ Dose: _________
 
Informed Consent
Manual osteopathy is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal and joints complaints. Although manual osteopathy has an excellent safety record, no health treatment is completely free of potential adverse effects. The risks associated with manual osteopathy. However, are very small. Many patients feel immediate relief following manual osteopathy treatment, but some may experience mild sores or aching, just as they do after some forms of exercise or massage. Current literature shows that minor discomfort or soreness following soft tissue therapy typically fades within 24 hours. I understand that I am entitled to know about my diagnosis and treatment, including the costs, benefits, risks and potential side effects. I hereby request and consent to the performance of osteopathic manual therapy performed by the osteopathic practitioner Akram Naserianaraki. I have had the opportunity to discuss with the osteopathic Akram Naserianaraki any questions or concerns that I have regarding my condition and any forms of therapy to be administered. I understand that the results are not guaranteed. I understand and am informed that, as in all health care, there are some very slight risks to treatment, including but not limited to, muscle aches and soreness following treatment. I do not expect the osteopathic practitioner to anticipate and explain all risks and complications. And I wish to rely on the osteopathic practitioner to exercise their judgment and I understand that all procedures are in my best interests. I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
I understand that 24 hour notice is required to cancel an appointment or I will be responsible for a 50% late cancellation
fee:
Client Signature: ____________________________________ Date: ___________________
 
Thank you for taking the time to fill out this questionnaire. It will greatly help in our study of present health concerns and our understanding of your health goals. Your responses will assist us in choosing the appropriate treatment that will hopefully bring about your return to optimal health. Consent to the Collection, Use, and Disclosure of Personal Information NOTE TO CLIENT: In accordance with the privacy act effective January 2004, we must ask for your informed consent. This means we want you to understand what we do with personal information. Your signature below allows us to obtain this information to open a confidential file for you. This is the only reason we collect your personal information. I understand that you provide me with Manual Osteopathic goods and services, Precision Manual Osteopathy will collect some personal information about me (e.i. telephone, birthday, address,etc…). We use and disclose your personal health information to: ● Treat and care for you ● Plan, administer and manage our internal operations ● Conduct quality improvement activities ● Teach ● Compile statistics ● Comply with legal and regulatory requirements We take steps to protect your personal health information from theft, loss and unauthorized access, copying, modification, use, disclosure and disposal. We conduct audits and complete investigations to monitor and manage our privacy compliance. We take steps to ensure that everyone who performs services for us protect your privacy and only use your personal health information for the purpose you have consented to. I understand that only if I check off the following statement I will NOT receive the following: ❏ Newsletters and other informational emails from Precision Manual Osteopathy ❏ I also agree to use my testimonial about my condition in public such as clinic, website, business cards, and flyers. I understand that, as explained in the policies and procedures for personal information, there are some rare exceptions to the commitments. I agree to Precision Manual Osteopathy collecting, using and disclosing personal information about me as set out and in the Precision Manual Osteopathy privacy policy Patient/Guardian Signature: ___________________________________ Date: ____________
Patient’s Printed Name : _________________________________________________________

OSTEOPATHY TREATMENT

“With every piece of the whole aligned in perfect harmony shows. In addition, That the body has the power to achieve its optimal performance potential”. First of all, manual osteopathy is based on the tension concept that emphasizes the structural totality of the body. Yes, In other words, Then focusing on the optimal positioning of the fascia, bones, muscles, viscera and everything in-between. After that, practitioners help clients reinforce these connections. Osteopathy THERAPY is the study of the human body as it functions in both health and disease. Above all, and strengthening overall function and performance. In addition, manual osteopathy takes a concern of whole-body approach to healthcare. Further more, it uses manual ‘hands-on’ techniques. Similarly, In short, which improve circulation. and correct altered to In conclusion, the  movement or structure with natural pain relief. So, Above all, But no using of drugs. Treatment Plan In order to diagnosing and treating. conditions using these techniques is called Osteopathic Manipulative Medicine (OMM). Which techniques include stretching and gentle pressure and resistance. Therefore, Each body has an individual structure. However, Because every case is different that no treatment program is the same. Above all, Therefore, clients play an active role in their own recovery. Which incorporates prescribed exercises to encourage faster and long-lasting results. Of course, In addition, That the body has the power to achieve its optimal performance potential”. First of all, manual osteopathy is based on the tension concept that emphasizes the structural totality of the body. In other words, Then focusing on the optimal positioning of the fascia, bones, muscles, viscera and everything in-between. After that, practitioners help clients reinforce these connections. Above all, But no using of drugs. Treatment Plan In order to diagnosing and treating. conditions using these techniques is called Osteopathic Manipulative Medicine (OMM). Which techniques include stretching and gentle pressure and resistance. Therefore, Each body has an individual structure.

WHAT IS OSTEOPATHY?

Osteopathy THERAPY is the study of the human body. as it functions in both health and disease. Similarly, In other hands, our bodies are a complex group of connected systems and integrated organisms. As a result performance is directly tied to how well the functions within our body work in harmony with one another. After that,is to say, manual osteopath use a unique combination. of careful palpatory. mobilization and muscle energy techniques. Therefore assess your entire structure to find the root cause of your discomfort. Similarly,  Therefore, we create a customized treatment plan to guide rehabilitation and prevent future health problems. Above all, On the other hand, In other words, this comprehensive approach is specifically. designed for each client’s individual recovery journey. To clarify, osteopathy is a comprehensive recovery tool which compliments and supports orthodox medicine. In conclusion, it combines the scientific knowledge of the conventional medical sciences. ok, THERAPY is the study of the human body. as it functions in both health and disease. with specialized methods of evaluation and treatment. THERAPY is the study of the human body as it functions in both health and disease. After that,is to say, manual osteopath use a unique combination. of careful palpatory. mobilization and muscle energy techniques. Similarly, Therefore, we create a customized treatment plan to guide rehabilitation and prevent future health problems.