Initial Consult Form (Neurological)

Neurological Initial Consult Form

First Name

Last Name

DOB (dd/mm/yy)

Age

Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Occupation

Hobbies

GP Details

Specialist Details

Please list your top 4 health concerns:

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

How did your symptoms start initially?

How have your symptoms changed over time?

What makes your symptoms worse?

What makes your symptoms better?

Out of 10, how much are your symptoms interfering with your work?

Out of 10, how much are your symptoms interfering with your hobbies/exercise?

Out of 10, how much are your symptoms interfering with your sleep?

Out of 10, how much are your symptoms interfering with your socialising?

Out of 10, how much are your symptoms interfering with your relationships?

What therapies have you tried so far?

What was the most effective?

Have you had any scans? If yes what were the results?

Medical History

Are you currently on any medications? If yes, please specify.

Previous medications:

Previous infections (please include dates):

Car accidents or Concussions (please include dates):

Musculoskeletal Injuries:

Recreational drug use:

Surgeries (please include dates):

Other information

Please use the space provided to give any further information you feel is relevant.

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

TENS is a treatment that administers mild electrical currents to the skin to relieve pain. A small, lightweight, hand-held, battery-operated device produces the electrical currents and lead wires send these currents to self-adhesive electrode pads that attach to your skin. While using a TENS machine, you will experience a non-painful tingling or buzzing sensation, and this can help to block or supress pain messages. Although TENS treatment is safe for most people, it is recommended that the following people avoid treatment: a) Pregnant women should avoid using TENS in the abdominal and pelvic regions b) People with epilepsy should avoid applying electrodes to the head or neck as it may induce seizures c) People with heart problems d) People with a pacemaker or another type of electrical or metal implant

I consent to TENS therapy

I do not consent to TENS therapy

Cancellation and Payment Information At Brain and Body Health, we use Tyro Health to collect and store patient card details securely. This system supports our policy on late cancellations and no-shows. Cancellation Policy We require at least 48 hours’ notice for any appointment cancellation. If sufficient notice is not provided, the full appointment amount will be charged. Less than 24hrs notice incurs 50% on the consult fee. Not showing up to your appointment is 100% of the fee charged. Please note, if you do not consent to our policy, we can not take you on as a patient.

I consent to the payment policy

I do not consent

Walk Out & Pay Policy Sometimes you’ll be in a hurry, or the clinic will be busy. The benefit of having your card details securely stored means you can dash out if you’re in a hurry, and we can process the payment and send through your invoice. This convenient option ensures a smooth and efficient experience for you.

I consent to the walk out and pay policy

I do not consent to the walk out and pay policy

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