Consent Form | Home Therapy

Select Date of Birth

Emergency Contact Information

Emergency Contact Name

Emergency Contact Number

Your Medical History

It is important that you answer these questions as honestly as possible to ensure you receive the best possible treatment. If you are not happy about any of the disclosure, please discuss this with your therapist, as these conditions or medications could have an effect when having an assessment or treatment.

Are you on any medication or have been in the last 6 months? If yes, please specify.
Yes No

Are you taking steroids or have been in the last 6 months?
Yes No

Do you have any history of kidney or liver conditions? If yes, please specify
Yes No

Kidney or liver condition notes

Have you ever had trouble with your heart? If yes, please specify
Yes No

Heart Condition Notes

Have you ever had problems with your chest? If yes, please specify
Yes No

Chest Condition Notes

Do you have any allergies? If yes, please specify
Yes No

Do you suffer from high or low blood pressure?
High Low No

Have you ever had Diabetes? If yes, please specify
Yes No

Do you have a thyroid problem?
Yes No

Do you have Arthritis? Rheumatoid or Osteoarthritis? If yes, please specify
Yes No

Have you ever injured or suffered from pain in the knees, hips or lower back? If yes, please specify
Yes No

Do you have or have you had Epilepsy?
Yes No

Do you have fainting attacks or blackouts?
Yes No

Have you had surgery or recently been in hospital? If yes, please specify.
Yes No

Have you had any infections such as MRSA, TB, HIV, Hep B or C?
Yes No

Do you have any other medical conditions that we should be aware of? If yes, please specify.
Yes No

Other Medical conditions Notes

Is there a history of illness in your family? If yes, please specify.
Yes No

History of illness notes

Are you pregnant?
Yes No

Do you use tobacco products?
Yes No

Do you drink alcohol?
Yes No

Do you have any eyesight or hearing difficulties? If yes, please specify.
Yes No

Eyesight or hearing difficulties notes

Your GP's Information

Consent to being treated by a Therapist

Consent given is in light of full information of risk of failure or complication as well as alternative therapies available.

I hereby give consent that I am to be seen or treated by a therapist. I hereby give consent that I am aware that therapist may use medical instruments. I hereby give consent to anonymised photographs and/or videos for marketing purposes. I hereby give consent to the use of the following: Clinical photographs/recordings for my personal health record only. I hereby give consent to anonymised clinical photographs/recordings to share with other health professionals to seek advice and/or to provide education. This includes case studies.

New Patients - Consent Form

Emergency Contact Information

Your Medical History

Your GP's Information

Consent to being treated by a Therapist

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