Confidential Client Health Summary Form

Why do I need to fill this in?

  • For all NEW clients – decongestive lymphatic therapy –> lymphoedema, lipoedema, pre and post surgery, liposuction, manual lymphatic drainage
  • Gives us a better understanding of your main pain problems and reason for the consultation
  • More “hands-on” treatment time if we are not filling out paperwork during your visit
  • Secure and confidential

 

Health Summary Form

Health Summary

Confidential Client Health Summary Form

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Name* DOB*
Email* Occupation
Address City
Postcode State
Mobile* Home phone
Work phone
GP Doctor GP Doctor Phone

Do you have Private Health Insurance with Extras cover?
If Yes, what is your fund name

MEDICAL HISTORY (please tick if relevant)

Heart Condition Circulatory problems
Stroke/CVA High blood pressure
Low blood pressure Varicose Veins
Infectious Disease Prosthesis
Rash Athlete's Foot
Tinea Allergies
Asthma / Lung Condition Seizures
Abdominal / Digestive problems Epilepsy
Skin Disorders Arthritis
Vision Problems Hearing Problems
Osteoporosis Diabetes
Cancer Tumours
Depression/Anxiety Fatigue
Chronic Pain Accident / Trauma
Bone Injury (e.g. fracture, dislocation) Muscle/Ligament Injury
Motor Vehicle Accident Bike Accident
Headaches / Migraines    

OTHER CONDITIONS not listed

CURRENT MEDICATIONS (including over-the-counter, herbal)

RECENT SURGERY

PREVIOUS TREATMENT IN RELATION TO THIS PROBLEM eg: chiropractic, massage

CURRENT COMPLAINT / SYMPTOMS:
Which of the following describes what you are experiencing?

Type of Symptom
Describe the Severity
How Constant are your Symptoms?

GOAL - you may have several areas of pain and discomfort, what is your priority for today's treatment?

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