Osteopath Assessment & Consent

905-901-0009

bodyflexclinic@gmail.com

3050 Confederation Pkwy #201, Mississauga, ON L5B 3Z6, Canada

Osteopath Consent Form

"*" indicates required fields

Step 1 of 2

First Name*

Last Name*

Date of Birth*

Type of work*

Blood Group*

Height

Weight

HISTORY OF PRESENT ILLNESS

Chief Complaints*

Using the following Pain Scale, rate your pain:

Type of pain*

Onset*

Time*

Duration*

Intensity*

Initial Factor*

Aggravating Factor*

Relieving Factor*

Past History – History of Similar Complaints / Episodes*

Previous treatment*

GENERAL INFORMATION:

Sports – Type / Frequency

Sleep – how many hours?

Disturbed sleep pattern (Morning or Night)?

What is the Comfortable position?

Food – Sweet/Salty/Spicy

Allergies

Radiographs

OTHER MEDICAL HISTORY:

Please state your previous medical history since and including birth if you are aware.

Traumatism:

Accidents:

Operations:

Fractures and breaks:

Sprains:

Pregnancy/C-Section/Abortion:

Addiction:

Other hospitalisations:

Medication past or present:

Other information (that may be seemingly irrelevant yet could well be):

Client Consent to Assessment/Treatment Treatments may include manual the rapist where the health practitioner places his or her hands on your body. Many techniques will include contact between your body and the practitioner’s body. The Body and hand contact may include areas of your chest wall, pelvic floor and pubic bone. If intraoral work is required (work inside the mouth) disposable latex or vinyl gloves will be worn. At times, the practitioners may ask you to remove some items of clothing to facilitate treatment. If you do not feel comfortable with any part of the treatment, please tell the practitioner immediately. The techniques can be discontinued or modified to be comfortable for you. Consent re: Personal Information and Treatment I value the trust you have placed in the practitioners, and I am taking all appropriate measures to safeguard your personal information confidence. I request that you provide your consent as set out below:

I,*

have informed the Manual Osteopath of all my known physical conditions,mental conditions and medications, and I will keep the Therapist updated on any changes.

I understand that the possible risks and benefits of osteopathy will be explained to me regarding my individual treatment plan and accept responsibility to inform the rapist if I do not understand any aspect of the risks and benefits. I understand that manual osteopathy is not a substitute for medical treatment and/or medications and that it is recommended that I work concurrently with my Primary Caregiver for any conditions I have. I am acknowledged that the treating manual osteopath/doctor/consultant/physician and his/her team of doctors have explained in the language I understand about the diagnosis and prognosis of my present heal the condition and explained to me in detail the treatment procedures, and protocols. I agree to protect the clinic, doctors, nurses, therapists, hospital staff, and administration from any legal issues, costs, or claims that may happen due to unexpected problems during my treatment. I understand and accept the clinic’s treatment costs.

Signature( please use your First name and Last name):*

DATE:*

All information provided by you is strictly confidential and will not be released without written consent except where required by law.

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Osteopath Assessment & Consent

Osteopath Consent Form

HISTORY OF PRESENT ILLNESS

GENERAL INFORMATION:

OTHER MEDICAL HISTORY:

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