Osteopathy Intake Form

Overview

First Name *

Last Name *

Birth date *

Lifestyle factors

Employment *

Occupation

Average working hours per week

0-15 hours 15-30 hours 30-40 hours 40+ hours

Physical Activities *Hobbies, interests, exercise. If exercise, include details about type, how often and for how long.

Handednesss *

Left Right Ambidextrous

Goals & experience:

Goals/aims from the consult: *

Have you seen an osteopath before? *

Yes NoOther manual therapist

Main Complaint

In this section please complete details ONLY about your main complaint/injury. This is generally for only one part of your body. There is a section later in the form for other complaints (if present).

When & how did your symptoms/injury begin? *If your complaint occured acutely, provide details about the date and how it occured, e.g. January 2022, after cutting firewood. If your complaint occured gradually, specify a rough estimate of how long you've had the problem and what may have contributed to it starting, e.g. gradual onset over last 5 years from sitting at work.

Since your injury/complaint began is it? *

ImprovingWorseningAbout the same

Site of your injury/complaint: *e.g. left shoulder, central low back, bottom of right foot.

Describe your symptoms: *e.g. sharp with movement, ache, throb, pulsating.

My complaint is: *

ConstantComes and goesWorse in morningsWorse in afternoon/evenings

Do you have numbness, tingling or weakness? *e.g. numbness in right foot.

What factors aggravate your injury/complaint? *e.g. standing, sitting, walking, running, laying down, reaching, lifting.

Are there any other factors to note about your complaint? *

Have you significantly injured the area in the past? *e.g., whiplash from a car accident.

Other Complaints

If you have other complaints, provide as much relevant detail about them as you can.

Medical information

Medical conditions (current & past): *Provide details about the date you were diagnosed and if and if the condition still affects you. E.g. type 2 diabetes since 2014, managed medically, glucose levels stable.

Allergies *Including tapes, creams etc.

Medications/supplements *If possible, provide details about dosage.

Surgeries *Provide details about the date, body region and if you have fully recovered. E.g. right knee replacement 2018, still stiff when bending. Gallbladder removal 2015, no ongoing issues.

Family medical history *Provide details regarding who is affected and what condition, e.g. heart disease, high blood pressure, stroke, certain cancers, and type 2 diabetes.

Do you smoke? *

Yes No In the past

Number of cigarettes per day

Less than 55 to 15More than 15

Female patients only section

Menstrual Cycle

RegularIrregularAbsent

Pregnancy

No previous pregnancyPast pregnancyCurrently pregnant 1st trimester (0-12 weeks)Current 2nd trimester (13-27 weeks)Current 3rd trimester (28-40 weeks)

Number of pregnancies:

To how many children have you given birth?

Consent to Osteopathic care

Please tick if you understand and accept the following:

Personal details need to be provided for osteopathic consults. Our privacy policy outlines what information we collect & your rights regarding the information that you supply to us. This policy can be read via our website http://promhealth.au/policies. It is also available at any time in the future upon request. *

The consult may involve partial disrobing (undressing). A gown will be provided upon request.
*

Treatment may involve some pain or discomfort. Your practitioner will try to minimise your pain and discomfort throughout the consult.
*

Constant and clear communication between myself and my practitioner is a key element in receiving care. *

You can always say no to any part of an osteopathic consult. Please tell us if this is the case. *

I understand & accept the risks associated with osteopathic consults as outlined below. *

1. Osteopathy is generally considered a safe form of health service.

2. However, we need to make you are aware of the risks associated with an osteopathic consult before deciding to receive it.

3. Osteopaths are trained health-professionals. We use our best clinical judgement to limit foreseeable risk to patients from treatment and openly discuss these risks.

4. There is risk associated with the examination, treatment & management we provide. Risk is relative to your individual circumstances & your particular consult.

Common risks to treatment include, but is not limited to:

Aggravation/making an injury worse
Soreness
Feeling tired, fatigued
Numbness or tingling
Headache

Serious risks to treatment are incredibly rare. There is a lack of evidence to conclude figures. Despite the rarity, these risks are believed to exist. Therefore, we need to make you aware of them.

They include:

Fracture/broken bones
Nerve root or spinal cord injury
Pneumothorax (punctured lung)
Worsening of disc herniations
Stroke & arterial dissections

Please type and electronically sign to accept terms outlined above:

* If you are under the age of 18, we may require a parent or guardian to sign on your behalf

Name: *

Signature: *

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