Personal Details Form

- Body Maintenance Centre

Emergency Contact Name & Number ……………………………………………………………………………………………………………..                                                                                                           

 

Referral Source (Please circle):   Medicare/Care Plan             DVA                 Workcover                  Other

 

Current Doctor…………………………………………    Practice Name …………………………………………………………………………..

 

Reason for Visit Today……..………………………………………………………………………………………………………………………………

 

Please tick all that apply.

I have:                                                                                    

  • Diabetes

  • Heart Disease

  • High Cholesterol

  • High Blood Pressure

  • Osteoporosis/Osteopenia

  • Rheumatoid Arthritis

  • Osteoarthritis

  • Musculoskeletal Conditions

(Please specify) …………………………..............................................

  • Cancer

  • Depression or anxiety

  • Epilepsy

  • Urinary Incontinence

  • Asthma/Respiratory Conditions

  • Had recent steroid/cortisone injection

  • Vertigo/Motion Sickness

 

Please list any relevant current and/or previous medical conditions including recent surgeries, previous injuries, etc. not listed above

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Please list any scans/tests you have completed in relation to your current condition/injury

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Please list any health practitioners/treatment you have previously/currently received in relation to your current condition/injury

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Health Goals: What aspects of your health would you like to improve?

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Disclaimer: As part of our ‘Duty of Care’ the following information will notify you of any risks associated with professional Physiotherapy treatment techniques. Such techniques used including massage, myofascial release, traction & joint mobilisations have a very small risk of causing injury.

 

A remote possibility of injury to structures such as but not limited to; nerves, bones, muscles, ligaments, discs or arteries exist. Allergic skin reactions to massage oils, strapping tapes or topical applications are a possibility. Massage techniques could possibly lead to minor bruising depending on medications, additional co-morbidities or other physiological factors.

 

Following the verbal explanation of my examination results and the therapeutic techniques the therapist decides to suit my condition; I give my consent to treatment. I have the right to decline treatment that the therapist offers me at the time. I have the right to a second opinion at any time.

 

I give permission to the therapist to exchange information with my doctor and other medical specialists, as well as teachers/coaches/trainers when necessary, unless otherwise notified. I understand that this information will be confidential.

 

Additionally, I take responsibility to notify my therapist of any infectious diseases that I am aware of and may be carrying (i.e. TB, HIV, Hepatitis, Glandular Fever, Golden Staph), as I understand the manual handling techniques mentioned above will enhance the possibility of contracting this/these diseases.

 

In relation to Medicare Chronic Disease Management Plan’s bulk billed sessions, if claim is denied from Medicare due to various circumstances, the balance of $53.80 will be paid out of pocket by the patient to Body Maintenance Centre.

 

Additionally, the patient must notify Body Maintenance Centre at least 24 hours prior for any cancellations or rescheduling of appointments otherwise a fee may occur depending on the circumstances.

 

                                                   

Thanks for submitting!