Perth Osteopathic Medicine

Patient History Form

Date: ______

Title: Mr / Mstr / Miss / Ms / Mrs / Dr / Other: ______Gender: M / F

Surname: ______First name: ______

Address:______

______Postcode: ______

DOB:______Age:______Occupation:______

Phone: (H)______(W)______(M)______

Email:______

Hobbies/Sports:______

Smoker: Yes / No Are you pregnant? Yes / No / Male

All current medications:______

Major hospitalisation or surgeries: ______

Major accident(s):______

Emergency contact name: ______

Phone number: ______Relation to you: ______

How did you hear about the clinic?: Internet Walked by Advertisement

Friend/ Family Doctor referral Other: ______

If referred by someone, who was it? ______CONSENT TO OSTEOPATHIC CARE

I understand, that as in all forms of health care, there may be some very slight risks as a result of osteopathic treatment. These may be:

 Not uncommon- muscle/joint soreness (especially after the first treatment).  Occasionally- temporary exacerbation and/or aggravation of symptoms.  Rare- nausea and/or dizziness.  Very rare- fractures, disc injuries.  Extremely rare- strokes and/or like episodes.

I am assured by Denis Winter (osteopath) that any questions I may have about my proposed care will be fully and honestly answered to the best of his ability.

I agree to rely upon his judgement, based on his knowledge of the facts of my condition at any time, to use the treatment most suited to my condition.

I understand this consent form will cover the entire course of my treatment for current and any future condition(s) for which I seek treatment from him. I understand my consent may be withdrawn by me at any time.

I agree to my osteopath communicating and seeking any information deemed necessary from my medical doctor.

Signed (patient):

…………...……………………………………………………...………………………

Signed (parent/guardian if patient is under 18):

……………………………………………………………………………...... Date: …………………………………………………………………………………….