Your body can
you want it to do.
Date of birth
Parent / Guardian Name: (if under 18 years of age):
Emergency Contact:* (Name & Phone):
Name of GP: (Medical Doctor):
Address of GP:
How did you find out about us (select one): FamilyFriendAdvertisingInternetClinic SignOther
If via friend / family member – please provide name:
Have you consulted another chiropractor/physiotherapist before? YesNo
If yes, name:
Date of last visit (approx):
List any treatments in the past that have helped:
List any treatments in the past that have not helped:
I consent to a physical examination that may involve partial undressing and having the
practitioner palpate (touch) me:
Please complete the following context of care information:
What can we help you with?*
Aggravating factors (makes worse):
Relieving factors (makes better):
Current health/lifestyle goals ie:What would you like to do that you are currently unable to do/ What do you hope to achieve by working with us?:
What does a typical training/exercise week look like? Who do you train with (gym/coach’s contact details)?
Do you smoke? yesno
Amount: / day
Do you consume alcohol? yesno
Amount (glasses): / day or / week
Do you currently suffer from any of the following:
Unexplained fevers yesno
Night sweats yesno
Abnormal bleeding yesno
Unexplained weight loss or gain yesno
Pain causing you to wake at night: yesno
Fatigue not relieved by sleep: yesno
Sudden onset of an intense headache you have never had before: yesno
Have any of your siblings, parents or grandparents suffered from (if yes, who and what condition):
Nervous system disease
Muscle, bone or joint conditions
Please list all surgeries, hospitalizations, traumas, disabilities and serious / chronic illnesses:
Have you experienced any of the following in the past month or since the onset of your main presenting health problem?
Nausea and/or vomiting : yesno
Fever and/or Rash : yesno
Fatigue not resolved with sleep : yesno
Weight loss or gain : yesno
Dizziness/vertigo/light headedness: yesno
Difficulty breathing : yesno
Chest pain or discomfort : yesno
Fainting or loss of consciousness : yesno
Decreased urinary/bowel control : yesno
Pain/blood in urine/faeces : yesno
Have you ever been diagnosed with any of the following health issues?
High blood pressure
Aneamia/low iron levels
Please read the following information carefully before signing.
Policies on Fees, Guarantees, Disclosed Information & Research:
1) I understand that appointments not attended or cancelled with less than 24 hours notice may incur a charge and that payment is required at the time of consultation. I will also discuss any consultation fees with a health practitioner or staff member at this clinic prior to the service being provided.
2) I appreciate that positive results of any treatment that I receive at The Functional Movement Club is not guaranteed.
3) I have disclosed any past or current illness, surgery, previous trauma, medications, drug use and any known health risks in the forms and questionnaires provided, and agree to provide any related new information during the period of care at this clinic or by practitioners who have assessed or treated me at this clinic.
4) Information gained from the initial assessment and follow up sessions may be used for internal research purposes or publishable research to help establish improved assessment and treatment protocols and promote a greater understanding of this field of healthcare in the scientific community. No personal details (name, contact details etc.) will be disclosed in any published material.
Risks of Care & Consent for Care:
5) Chiropractic and other techniques used at this clinic are well recognized as being extremely safe health care interventions for people of all ages. However, as with all health care disciplines there is a risk of complications. This may include, but are not limited to: soreness; muscle, bone or joint injury; worsening of symptoms; intervertebral disc injuries; nerve injuries; dizziness / light headedness; nausea; vision, hearing or balance problems; stroke (estimated at less than 1 per million); or side-effects caused by the use of nutritional or herbal products that may be recommended. If I have any concerns I will discuss them prior to treatment or during the course of a treatment program if any new concerns arise.
6) I understand that the abovementioned risks of treatment exist. However, I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care.
7) I hereby acknowledge my consent to undergo assessments – which may require photographic or video recording as part of my records – and treatment at this clinic. I intend this consent form to cover the entire course of treatment for my present complaint, and for any other future complaint(s) for which I may seek treatment. I understand that I may withdraw my consent at anytime without compromising my care in any way.
By signing below, I acknowledge that I have carefully read all of the above information and that I understand and agree to each point that is made.
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