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Intake

ALIGN OSTEOPATHY

INTAKE FORM

First name

Last name

Phone

Birthday

Year

Month

Day

Address

Occupation

How did you hear about my office?

What are your top 3 complaints/ reasons for seeking treatment?

Have you/Are you receiving care from other health care practioners?

Have you been in a car accident?

Yes

Have you ever experienced a fall to your tailbone? buttocks?

Yes

Have you ever experienced a hard blow to your head or had a concussion

yes

Have you ever had spinal surgery?

Yes

Do you have any pins, plates or screws in your body?

Yes

Please list any medications and reasons for taking :

Please list any surgeries/ accidents/traumas and year of occurance :

For Women: Do you have any children, If so how many?

For Women: are you pregnant now?

Client Consent to Assessment/ Treatment

Manual osteopathy is widely recognized as one of the safest drug-free, non-invasive therapies available for a the treatment of neuromusculoskeletal and joint complaints.

Treatments may include manual therapies where the health practitioner places their hands on your body.

Many techniques will involve contact between your body and the practitioner’s body. Body and hand contact may include areas of your chest wall, pelvic floor, and pubic bones. If intraoral is required (work inside the mouth) disposable latex or vinyl gloves will be worn.

At times, the practitioner may ask you to remove some items of clothing in order to facilitate assessment/treatment. If you do not feel comfortable with any part of the treatment, please inform your practitioner immediately. The techniques can be discontinued or modified as per consent.

I have informed the Osteopath of all my known physical conditions, mental conditions, and medications and I will keep the practitioner updated on any changes

I understand that there are possible risks and benefits of osteopathy and that they have been explained to me regarding my individual treatment plan and accept responsibility of informing my practitioner if I do not understand any aspect of the risks and benefits.

I am aware that all information provided to the clinic is strictly confidential and will not be released without my written consent.

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