Osteopathic Health information

  Precision Manual Osteopathy 
 604 440 5856 


● 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: _________
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. 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


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.
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 ❏ Further, 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.  Lastly, 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 : _________________________________________________________


Manual osteopathy is based on the concept of treating the body without any use of drugs. It is believed that the body functions perfectly if all the parts are in good condition. The osteopathists cure healthcare by manipulating the musculoskeletal system.  In other words, then focusing on the optimal positioning of the fascia, bones, muscles, viscera and everything in-between. In light of the fact, that the human body works in the coordination of all the organs, practitioners help clients reinforce these connections. The therapists do that by using their hands instead of equipments and medicines just like the massage. It is an effective treatment which brings relaxation to your body. Osteopathy not only cures you but the process is relaxing.

Simply put, Osteopathy Therapy is the study of the human body as it functions in both health and disease. As mentioned before that no drugs are used, the technique is quite similar to massaging but aimed to improve the healthcare of the overall body. Manual osteopathy would help improve the blood circulation and nervous system. Furthermore, it is beneficial for the treatment of neck pain, back pain and other sorts of pain relief. Treatment Plan for diagnosing and treating conditions using these techniques is called Osteopathic Manipulative Medicine (OMM). We recommend this therapy to our clients because of its effectiveness.


Osteopathy is the study of human body and its cures. An osteopathist is responsible to find out the truoble spots and cure it through therapy. However, it is especially beneficial for the cure of migraine, back pain, neck pain, etc. Manual osteopathy cures overall health of the human body. As we know that the human body consists of complex groups of connected systems and organisms. Therefore, all the organs of the human body should be in a good condition. Osteopathy ensures exactly that. 

The blood circulation is improved using this technique. In the same way, osteopathy improves the nervous system of the body by massaging. Moreover, the osteopaths focus on joints, muscles, and spine. Whole body of the patient is examined and the pain point is found, once it is found the relief can easily be provided. For this purpose, we have created a custom treatment plan to guide our patients to rehabilitation and prevention of future health problems. The clients can pre book an appointment.