New Patient Form

First name

Last name

Phone

Address

Date of birth

Medical History

Are you currently, or have you ever, suffered from or been diagnosed with any of the following:

Where the answer is yes please provide further details.

Heart problems.

High blood pressure.

Asthma.

Epilepsy or seizures.

Diabetes.

If yes please provide details:

Reason for visit

Please provide information regarding your reason for visit, whether that be an injury, ache or pain or advice regarding training etc

Long answer

Are you experiencing pain

Out of ten how would you rate the pain?

Is there a particular time when you experience the pain? I.e. first thing in the morning, after activity, after rest

Informed Consent

Sports therapy involves the use of many different types of physical evaluation and treatment. At Meridian, we use a variety of procedures and modalities to help us to try and improve your function. As with all forms of medical treatment, there are benefits and risks involved with sports therapy.

Since the physical responses to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your responses to a certain therapy modality or procedure. We are not able to guarantee precisely what your reactions to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions.

You have the right to ask your sports therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time or during your treatment session.

Therapeutic exercises are an integral part of most sports therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them.

I acknowledged that my treatment program has been explained by my therapist, and all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Sports Therapy as outlined to me, and I wish to proceed.

Signature

Date