Informed Consent Form
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3 Informed Consent Form The doctor of chiropractic evaluates the patient using standard examination and testing procedures. A chiropractic adjustment involves the application of a quick, precise force directed over a very short distance to a specific vertebra or bone. There are a number of different techniques that may be used to deliver the adjustment, some of which utilize specially designed equipment. Adjustments are usually performed by hand but may also be performed by hand-guided instruments. In addition to adjustments, other treatments used by chiropractors include physical therapy modalities (heat, ice, ultrasound, soft-tissue manipulation), nutritional recommendations and rehabilitative procedures. Chiropractic treatments are one of the safest interventions available to the public demonstrated through various clinical trials and indirectly reflected by the low malpractice insurance paid by chiropractors. While there are risks involved with treatment, these are seldom great enough to contraindicate care. Referral for further diagnosis or management to a medical physician or other health care provider will be suggested based on history and examination findings. Listed below are summaries of both common and rare side-effects/complications associated with chiropractic care. Common 1.2 Reactions most commonly reported are local soreness/discomfort (53%), headaches (12%), tiredness (11%), radiating discomfort (10%), dizziness, the vast majority of which resolve within 48 hours. Rare 3.4 Fractures or joint injuries in isolated cases with underlying physical defects, deformities or pathologies Physiotherapy burns due to some therapies Disc herniations Cauda Equina Syndrome (2) (1 case per 100 million adjustments) Compromise of the vertebrobasilar artery (i.e. stroke) (range: 1 case per 400,000 to 1 million cervical spine adjustments [manipulations]). This associated risk is also found with consulting a medical doctor for patients under the age of 45 and is higher for those older than 45 when seeing a medical doctor. Please indicate to your doctor if you have headache or neck pain that is the worst you have ever felt. I understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. I also understand that my condition may worsen and referral may be necessary if a course of chiropractic care does not help or improve my condition. Reasonable alternatives to these procedures have been explained to me including prescription medications, over-thecounter medications, possible surgery, and non-treatment. Listed below are summaries of concern with the associated alternative procedures. Long-term use or overuse of medication carries some risk of dependency with the use of pain medication the risk of gastrointestinal bleeding among other risks Surgical risks may include unsuccessful outcome, complications such as infection, pain, reactions to anesthesia, and prolonged recovery 5. Potential risks of refusing or neglecting care may result in increased pain, restricted motion, increased inflammation, and worsening of my condition 6. Neck and back pain generally improve in time; however, recurrence is common. Remaining active and positive improve your chances of recovery. 1. Thiel HW, Bolton JE, Docherty S Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spina. Oct ;32(21): ; discussion Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW. The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study. J Manipulative Physiol Ther. Jul-Aug 2007;30(6): Cassidy JD, Boyle E. Cote P, et al. Risk of vertebrobasilar stroke and chirpractic care: results of a population-based casecontrol and case-crossover study. Spine. Feb :33(4 Suppl):S Boyle E. Cote P, Grier AR, Cassidy JD. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine. Feb :33(4 Suppl):S Carragee EJ, Hurwitz EL, Cheng L, et al. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders. Spine. Feb :33(4 Suppl):S75-82.
4 PLEASE DO NOT SIGN THIS FORM UNTIL AFTER YOUR TREATMENT PLAN HAS BEEN REVIEWED WITH YOU BY YOUR DOCTOR Please answer the following questions to help us determine possible risk factors: QUESTION GENERAL Have you ever had an adverse (i.e. bad) reaction to or following chiropractic care? BONE WEAKNESS Have you been diagnosed with osteoporosis? Do you take corticosteroids (e.g. prednisone)? Have you been diagnosed with a compression fracture(s) of the spine? Have you ever been diagnosed with cancer? Do you have any metal implants? VASCULAR WEAKNESS Do you take aspirin or other pain medication on a regular basis? If yes, about how much do you take daily? Do you take warfarin (Coumadin), heparin, or other similar blood thinners? Have you ever been diagnosed with any of the follow disorders/diseases? Rheumatoid arthritis Relter s syndrome, ankylosing spondylitis, or psoriatic arthritis Giant cell arteritis (temporal arteritis) Osteogenesis imperfecta Ligamentous hypermobility such as with Marfan s disease, Ehlers-Danlos syndrome Medial cystic necrosis (cystic mucoid degeneration) Bechet s disease Fibromuscular dysplasia Have you ever become dizzy or lost consciousness when turning your head? SPINAL COMPROMISE OR INSTABILITY Have you have spinal surgery? If yes, when? Have you been diagnosed with spinal stenosis? Have you been diagnosed with spondyliolithesis? Have you had any of the following problems? Sudden weakness in the arms or legs? Numbness in the genital area? Recent inability to urinate or lack of control when urinating? YES DOCTOR S COMMENTS I have read the previous information regarding risks of chiropractic care and my doctor has verbally explained my risks (if any) to me and suggested alternatives when those risks exist. I understand the purpose of my care and have been given an explanation of the treatment, the frequency of care, and alternatives to this care. All of my questions have been answered to my satisfaction. I agree to this plan of care understanding any perceived risk(s) and alternatives to this care. PATIENT [or PARENT/GUARDIAN] SIGNATURE DATE INTERN SIGNATURE DATE DOCTOR S SIGNATURE DATE
5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, have received a copy of this office s Notice of Privacy Practices. Please Print Name Signature Date For Office Use only We attempted to obtain acknowledgement of receipt of our Notice of Policy Practices, but acknowledgement could not be obtained because: Individual Refused to Sign Communication barriers prohibiting the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify)
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PREVIOUS BIRTH EXPERIENCE
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Adult Health Questionnaire
Health for Life Chiropractic At Cloverdale Mall Unit #143-250 The East Mall Etobicoke, ON, M9B 3Y8 416-232-1822 416-232-0060 Dr. Chrystopher Sly B.Sc, D.C. Dr. Jesse Cracknell B.A., D.C. Adult Health Questionnaire
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