Pre Consult Form

Please note that all fields marked with * are required.

Personal information

Reason for attending this clinic


A specific concernGeneral health advicePreventative care

If you have a specific injury or complaint, please answer the following questions, if relevant:


ImprovingUnchangingWorsening


YesNo

General history

Lifestyle


RegularlyIrregularlyRarely or never



ExcellentFairPoor


ExcellentFairPoor


HighMediumLow

Have you noticed any of the following?


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes

Practice policy

As a patient of Cartwright Physicaltherapy I agree to:

  1. Attend at the allocated appointment time.
  2. Provide at least 24 hours notice if I cannot attend my appointment.
  3. Pay a late cancellation fee in the event 24 hours notice of cancellation has not been provided (at the discretion of the practitioner)
  4. Bring suitable clothing to the appointment (gym shorts/tights, singlet/top/sports bra). This enables the practitioner to examine your area of concern adequately.
  5. Settle my account before I leave the practice.
  6. Disclose any past or current illness, surgery, previous trauma, medications, drug use and any known health risks in this pre-consultation form, and agree to provide any related new information during the period of care at this practice or by practitioners who have assessed or treated me at this practice.
  7. Be contacted via SMS/email service for appointment reminders, prescribed exercises and to receive a monthly newsletter, all of which can be unsubscribed to at any time.
  8. Information gathered from my time in treatment at this practice being used for scientific research purposes to improve this field of healthcare. Personal details will never be disclosed in any publishable material.
Consent to care
  1. I acknowledge the physical therapy techniques used at this practice may include spinal manipulative therapy; joint mobilisation; the McKenzie Method; soft tissue massage including Active Release Technique [ART]; nutritional advice; exercise prescription; dry needling; and/or supportive taping.
  2. Whilst these therapies are recognised as being safe and effective interventions for people of all ages, and are well established in the history of practice, I understand as with all health care disciplines, that there is a risk of complications. These may include muscle soreness; aggravation of the condition; bone or joint injury; stroke (
    <1 case in one million); sprain/strain/rupture to intervertebral disc or ligament; bruising; headache or light-headedness.
  3. I will inform my practitioner of any particular therapy I wish not to have.
  4. I understand my consent does not waive my Common Law Rights.
  5. I hereby acknowledge my consent to undergo assessment and treatment at this practice and understand that I may withdraw my consent to care at any time. By adding your full name below, you acknowledge that you have carefully read all of the above information and that you understand and agree to each point that is made. You will be asked to sign a printed copy of this form when you present at the initial consultation.
Acknowledgement

By adding your full name below, you acknowledge that you have carefully read all of the above information and that you understand and agree to each point that is made.