<p> Perth Osteopathic Medicine</p><p>Patient History Form</p><p>Date: ______</p><p>Title: Mr / Mstr / Miss / Ms / Mrs / Dr / Other: ______Gender: M / F </p><p>Surname: ______First name: ______</p><p>Address:______</p><p>______Postcode: ______</p><p>DOB:______Age:______Occupation:______</p><p>Phone: (H)______(W)______(M)______</p><p>Email:______</p><p>Hobbies/Sports:______</p><p>Smoker: Yes / No Are you pregnant? Yes / No / Male </p><p>All current medications:______</p><p>Major hospitalisation or surgeries: ______</p><p>Major accident(s):______</p><p>Emergency contact name: ______</p><p>Phone number: ______Relation to you: ______</p><p>How did you hear about the clinic?: Internet Walked by Advertisement</p><p>Friend/ Family Doctor referral Other: ______</p><p>If referred by someone, who was it? ______CONSENT TO OSTEOPATHIC CARE</p><p>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:</p><p> 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.</p><p>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.</p><p>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.</p><p>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 I understand my consent may be withdrawn by me at any time.</p><p>I agree to my osteopath communicating and seeking any information deemed necessary from my medical doctor.</p><p>Signed (patient): </p><p>…………...……………………………………………………...………………………</p><p>Signed (parent/guardian if patient is under 18): </p><p>……………………………………………………………………………...... Date: …………………………………………………………………………………….</p>