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Your Personal Health Information and your Health Record may be collected, used and disclosed for the following reasons:

For communicating with other treating medical professionals, for follow-up/reminder calls, for discussion with third party insurers, accounting/Medicare/health insurance procedures, disease notification as required by law, for use by all physiotherapists in this practice when consulting with you and for legal disclosure as required by a court of law.

If you have any concerns or wish to restrict access to your information please discuss these with your physiotherapist or receptionist. This practice adheres to National Privacy Principles (www.privacy.gov.au)

Your "Informed Consent" is required for all treatment provided by this practice.

• You may withdraw your consent at any time. Treatment will cease if consent is withdrawn.
• If you become uncomfortable with your treatment at any time please inform your physio.
• All forms of treatment carry some risk. Risks will be explained prior to treatment at which time you may choose to continue or discontinue treatment.

Are you making a claim for this injury?

CONFIDENTIAL PATIENT CASE HISTORY

As a Physiotherapy practice providing comprehensive care, we focus on your ability to be healthy. Our goals are: firstly, to address the issues that brought you to this practice; secondly, to treat the cause of your condition (not just treat the symptoms or place a temporary patch over your condition); and thirdly, to offer you the opportunity of improved health potential and wellness services in the future. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health. Most times the effects are gradual: not even felt until they become serious. Answering the following questions will give us a profile of your health. Your Physiotherapist will use this information to assist them in taking a comprehensive history.

If you are experiencing pain is it:

Since the problem started is it: