Physiotherapy – Initial Consultation

First Name*

Surname*

DOB*

Address*

Suburb*

Postcode*

Mobile*

Work

Marital Status

Email*

Occupation

Sex*

Private health insurance

Medicare

Workcover / CTP claim?

Claim no

Dept of Veteran's Affairs

GP or Medical Practice details

How did you hear about us?

If Word of Mouth or Other, please indicate who or where. If you found us through Google please indicate the keywords you entered into the search bar. eg North Sydney Chiropractic etc*

Your Presenting Problem

Major Complaint*

Date of onset*

Please indicate on a score of 0 to 10, how intense the pain is. (0=no pain, 10=extreme pain)

Pain Rating

Are there any other area/s of pain not included above? Are there any other associated symptoms associated with your pain? i.e. numbness, pins and needles, headache, blurry vision etc.

If you have any neck pain or headache, please indicate whether you are experiencing any of the following symptoms.

Dizziness
Visual loss or disturbances i.e. blurry visions, spots in eyes etc.
Clumbsiness or uncoordinated movements
Difficulty speaking
Throbbing or splitting headache unlike any other you have previously experienced
All of the above
None of the above

Have you ever sought any treatment for this complaint?*

Previous treatment i.e. Chiro, physio, osteo, massage, GP/Medical?

Any other complaints

General Health

Accidents (Incl car, bike, work etc)*

Details- when? any injuries sustained?

Previous surgery (incl. breast augmentation)*

Details- when and what for?

Medications*

Details- name and for what condition?

Supplements*

Details- name and for what reason?

Unexplained weight loss*

Please provide more details i.e. how many kgs over time.

Abnormal bleeding from any body part?*

Please proivide more details.

Recenty Changes to mole or freckles*

Please provide more details.

Lifestyle and Wellness

Exercise*

Details- how often? what type?

Sports*

Which sports?

Diet*

Particulars about your diet i.e. allergies or intolerances. avoiding anything specific?

Sleep*

How many hours per night? Quality? Dreams/Nightmares?

Sleeping Position*

Stress*

Details Work / Home etc?

Smoking*

How many Cigarettes/Packs per day/week.

Alcohol*

Drinks per day/week?

Any other Health Related issues? (i.e.heart problems, diabetes, hypertension, cancer, depression and anxiety, asthma, arthritis and/or osteoporosis?

If you could improve anything about your health, what would be your goals?

1:

2:

3:

Treatments

The practitioners at North Sydney Sports and Chiropractic may use any of the following therapies in your care:

Spinal Manipulative/Adjustments
Soft Tissue Mobilization
Exercise Rehabilitation

Nutritional therapy/advice
Taping Techniques
Dry Needling Techniques

The therapies offered by the practitioners at North Sydney Sports and Chiropractic have a long history of practice; however as with all treatments there are some inherent risks. These include:

Aggravation of an existing condition
Headache
Rupture to disc
Sprain/Strain to disc or ligament
Infection

Stroke or stroke-like symptoms
Relaxed or sleepy feeling
Bruising or muscle soreness
Sprain/strain to muscle or tendon
Fracture

Please tell your practitioner if you do not want a particular type of treatment.

I understand the possible risks of the treatment outlined above.
I give consent to the proposed care by any practitioner who operates at North Sydney Sports and Chiropractic.
This consent does not waiver your Common Law Rights; rather it is merely for you to acknowledge that you have been informed of the common known risk.
I understand that I can withdraw my consent to treatment at any time
I give consent to my patient notes to be shared with practitioners/therapists that work within North Sydney Sports and Chiropractic and will not be used for any other purposes than the treatment of my condition and health.

*

I hereby acknowledge that I have read and understand the information above. I give my consent to continue with the proposed treatment.