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). Similarly, 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: _________
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. Also, the current literature shows that minor discomfort or soreness following soft tissue therapy typically fades within 24 hours.
Terms and Conditions
I understand that I am entitled to know about my diagnosis and treatment, including the costs, benefits, risks and potential side effects. Hereby, I request and consent to the performance of osteopathic manual therapy performed by the osteopathic practitioner Akram Naserianaraki. Moreover, 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 and understand that the results are not guaranteed. Moreover, 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 appointment.
I do not expect the osteopathic practitioner to anticipate and explain all risks and complications. In addition, I wish to rely on the osteopathic practitioner to exercise their judgment and I understand that all procedures are in my best interests and have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below and 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.
Also, I understand that 24 hour notice is required to cancel an appointment or I will be responsible for a 50% late cancellation
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.
Firstly, 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. Also, 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.
Patient/Guardian Signature: ___________________________________ Date: ____________
Patient’s Printed Name : _________________________________________________________