Microsoft word - new patient history form.doc

Full Name:______________________________________________ Address: _______________________________________________________________________ Suburb: ________________________________________________ Telephone No. (H): ___________________(W)_________________ (M) ____________________ Email address: __________________________________________________________________ No. of hours you work each week: ____ Marital Status: ________ Partners Name: ____________ Children's Names and Ages:________________________________________________________ Is to encourage and inspire our community to develop a healthy, vital lifestyle enhanced by Chiropractic care and the natural healing Current health complaints/reason for consulting our office: 1. _____________________________________________________________________________ 2. _____________________________________________________________________________ 3. _____________________________________________________________________________ 4. _____________________________________________________________________________ Have you had same or similar problem(s) before? _______________________________________ If so, for how long? _______________________________________________________________ Is this the result of an motor vehicle or work injury? _____ If so when? _______________________ Father, mother, brother, sister, children with problems?__ If so who? ________________________ Other doctors you have seen for this problem: __________________________________________ Surgeries you have had: ___________________________________________________________ Do you have any problems with your heart or lungs?_____________________________________ Do you have any problems with your stomach, intestines or urinary systems? _________________ When were you last in hospital? _____________________________________________________ What accidents/traumas/ stresses have you been involved in? _____________________________ Do you currently suffer from dizziness? _______________________________________________ Medications you are currently taking: _________________________________________________ Is there a chance you are pregnant: __________________________________________________ Have you ever been diagnosed with cancer? __________ If so, what kind? ___________________ Do you have health insurance? ___ Name of company: __________________________________ Level of Cover: __________________________________________________________________ Have you received an adjustment by a Doctor of Chiropractic? _____________________________ When was your last visit? _________________________ Were you pleased with the service?____ Who may we thank for referring you? ________________________________________________ Is there anything else we need to know about before we begin? ____________________________ Patient Information – INFORMED CONSENT Chiropractic is recognised as being effective and safe form of healing. In fact due to the wonderful results chiropractic is the largest drug free health care profession in the world. However, you must recognise that there are risks associated with all health care procedures, including assessment and treatment, which you should be informed about. You will be tested before any adjustments are applied Very rare risks may include muscle soreness, strain to a ligament or disc in the neck or low back and aggravation of the underlying condition. Extremely rare is the risk of damage to neck blood vessels which can result in stroke or like symptoms. Such risks may result in outcomes such as referral, further tests, surgery, incapacity and the like. Chiropractic adjustments of the spine are internationally recognised as being far safer than medication and many other alternatives (see below). I acknowledge the above information and do not expect the Chiropractor to be able to anticipate all potential risks and complications associated with the proposed care. I have had the opportunity to discuss the proposed care. I also acknowledge that I have had the opportunity to ask questions about the nature, extent and purpose of the proposed chiropractic care and that I have been given sufficient time to make a decision giving consent for the care to proceed. I acknowledge that I am aware of and understand the potential risks. I appreciate that results are not guaranteed. I hereby acknowledge my consent to the performance of the proposed chiropractic care by Andrew Iggo and/or any other chiropractor working in this clinic. I understand that I can withdraw consent at any time. Based on all the information provided, I consent to and look forward to receiving Chiropractic care at this office. --------------------------------------- (Please sign in presence of Chiropractor) Andrew Iggo --------------------------------------- - (temporary) Radiculopathy associated with disc injury…………….1:139,000 Vascular injury ………………………………………………1:1.2 million - 1:5.85 million Lumbar Spine Disc injury with radiating pain ………………………………………………1:62,000 Radiculopathy (nerve damage)…………………………………………….1:188,000 Cauda Equina Syndrome ……………………………………………………1:565,000 IN COMPARISON Hospitalisation for Gastro-Intestinal Bleeding (NSAID) …….…………….1:250 (following one month of medication) Deaths associated with non steroidal anti inflammatory (U.S) …………………………………….3200 p.a eg, Voltaren, Nurofen, Naprosyn (AUS) ……………………… ………….360 p.a Death from general anaesthetic …………………………………………….1:1250 Death from Cancer (all kinds) ……………………………………………….1:555 Injury from Motor Vehicle Accident ………………………………………….1:9300 Hospitalisation for adverse drug reactions ……………………20,000 to 26,000 p.a

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