Initial Consult Form (MSK)

Initial Consult Form (Standard)

First Name

Last Name

DOB (dd/mm/yy)

Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Occupation

Hobbies

GP Details

Specialists Details

Please list your top 3 health concerns:

Where abouts do you feel your symptoms in your body?

How does it change over time?

What aggravates your pain?

Out of 10, please rate how much the above health concerns interfere with you; family life, sleep, work, hobbies or exercising

How did it start?

Have you tried other therapies? If you have, please specify.

Have you been given a diagnosis? If you have, please specify.

Have you had any previous scans done? If you have answered yes, please specify your reuslts in the following question.

Yes

Results of previous scan/s?

Are you experiencing any of the following, now or recently ?

Chest-pain

Jaw Pain

Change in appetite

Excessive sweating

Pale skin or Pallor

Recent Fatigue

Light-headedness

Shortness of breath

Recent fever

Blackouts

Unexplained weight loss/gain

Vertigo/dizziness

Motion sickness

Claustrophobia

Fear of heights

Please read this consent form, discuss it with your practitioner if you would like to, and then provide consent where indicated. Patient Information: Chiropractic and other techniques used at this clinic are well recognised as being extremely safe health care interventions for people of all ages. However, as with all health care disciplines there is a risk of complications. This may include soreness, muscle, bone or joint injury, worsening of symptoms, vision, hearing or balance problems, stroke (estimated at less than 1 per million), or side-effects caused by the use of nutritional or herbal products that may be recommended. If I have any concerns, I will discuss them prior to treatment or during the course of a treatment program if any new concerns arise. Chiropractic adjustments (manipulation) of the spine are internationally recognized as being far safer in dealing with neck and low back pain than medication and many other alternatives. (A risk assessment of Cervical Manipulation JMPT, 1995. Manga Report, Ontario Ministry of Health 1993). I understand the abovementioned risk of treatment exist. However, I do not expect the practitioner to be able to anticipate all potential risk and complications associated with the proposed care. I hereby acknowledge my consent to undergo assessments and treatment at this clinic and understand that I may withdraw my consent at anytime.

I consent to Chiropractic care

I do not consent to Chiropractic care

Laser therapy is a safe and effective relief of pain and reduction of symptoms associated with mild arthritis and muscle pain. Laser also promotes relaxation of muscle spasm and promotes vasodilation. K-Laser device have TGA approval in Australia. FDA cleared in the USA and CE in Europe. Pain relief from laser therapy may be dramatic and substantial, lasting for hours, days or weeks. However, your results may be minimal or insignificant. Adverse effects from laser therapy are normally rare and temporary. They may occur from multiple causes including hypersensitivity, pre-existing health conditions, thermal effects such as burns, excessive pressure from the probe, and laser over-stimulation. Laser light can damage the retina in your eye. Always wear the laser protective glasses provided. The most common adverse effects are: a) Temporary increase in pain the following day after receiving laser therapy b) Mild bruising from vasodilation or direct pressure of the handpiece c) Temporary dizziness d) Skin reaction from photosensitising drugs (erythema/burn)

I consent to Laser Therapy

I do not consent to Laser Therapy

Dry needling is not acupuncture; however, it is a technique that utilises thin, solid filament needles. This needling technique is used specifically to treat myofascial trigger points, muscle spasms, or dysfunctional tissue. Like any medical procedure, there are possible complications. While these complications are uncommon, they do sometimes occur and must be considered prior to giving consent to the procedure. a) When a needle is inserted in the correct location, it may briefly reproduce a muscular ache or a twitching. You may experience a muscular ache for one or two days followed by an expected improvement in your overall symptoms. b) Any form of skin penetration creates an opportunity for bacteria to enter the system. Your massage therapist will follow the proper disinfection procedures and will use only the sterile disposable single-use needles. c) You may experience a small painless bruise or blood spotting in the treated region. Bruising and the blood spotting of this nature would clear very quickly. d) You may feel tiredness, nausea, dizziness, sweating; if this occurs, you will be asked to avoid driving until the feeling has passed. Changes in blood pressure, heart rate, flushing of the face or breathing rate are involuntary reflexes which may change temporarily because of dry needling; these occur rarely and should give no cause for concern. e) There have been approximately 100 reported cases worldwide of acupuncture needles puncturing a lung. This only occurs when needles are inserted too deeply or incorrectly. Your massage therapist has been trained to avoid the lungs and limit needle depth to avoid this occurring.

I consent to Dry Needling

I do not consent to Dry Needling

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