Consent and ROF Competency Form studentname: Thomas Hem age patient (nat ooh): 7X, (47) ‘Component Review of findings Diagnosis Plan of Management niversi muiversity Date: oufos[a / —Fapervizor Comments Further Investigation Risks and benefits Prognosis [ Discusses patient’s | right not to have treatment or seek other alternatives Patient Questions Consent and ROF Forms | rofestonal ieney Overall Mark: 4 B 7 3 7 z 5 a = Weak tnadequatel_| competent Good xcllent at atenptedor | fe amiariy, — Some faint /Aeuate Geodarasp of | Bllent soared | knowledge or | withconcepts, | understanding ot | concepts, proficient | knowledge of stiwith however concepts ommorication and | concepts and Tequred tasks | executes aonropite documentation | outstanding inadequately | communication and communication and documentation documentation Consent and ROF competency Marking Form_vi_ Mar 2020Supervisor's Additional Comments: ~ forfl poet 4 rego = ‘Self-refiection (to be completed by the what would you do differently next tim time you perform this procedure you wi In veflectiea 4) pareve wn tule ae more practi ny i+ down! ensave thay NST IN mere) nee ‘Ror. Eopectarty Simorityi Alor mers. Nddiitions toy Pee! \ Wodd go oven We \nfer pect CO detail. ' ‘Additional Learning Objectives / Suggestions for development: sumone 20~ 776 Mere A om Ooo Z| Supervisor Signature: Consent and ROF competency Marking Fotm_v_ Mar 2020| ©, Informed Consent for Chiropractic Care niver ‘SI AUSTRALIA ly i before undergoing a weatment a paint shoud understand the ‘The aim of the treatment always to Improve the patient's he relevant factors in relation tot, Ven bryhy shave consulted oa Cth) "have been advised thatthe appropriate treatment wl Involve B_thave had the individual treatments explained to me 'S Lunderstand that my prognosis is ‘ood ) St MY Prognosisis(tobe circled): poor guarded — fair good.) — exellent 1 Ihave had the licely effects of having no treatment explained to me, oe "have also been advised ofthe following issues related to the treatment tick os agreed) % _L-maminrty of cases the trestnet may rt besa may ete sae poston a som FL _2,atnouthtncommanthe veament nay make my don wore, : fa. Inthe case oftreatment tothe spine and enteritis legs and ams), temporary soreness may occur strains nd ‘sprains to the muscles, ligaments and other soft tissues occur but are uncommon; rupture to discs between the spinal vertebrae are ncommn btn theses eeu can ue wh anion pans hese tet and in rare instances this can cause permanent dis) bling pain and weakness in an arm or leg. and in very rare instances ! towel nd badder tncton rth soece anaes te 1 inthe case of menpltoner adnan ene re ave bet eprted orl cates oti to ate Inthenek: Tove vy ae en pipr eer they ue been Rene as are meee oe injury sch 5 unre oot Teoh tte tsp cvs eras 1 00), 1 a.mheatenatvesto the propeed wentnenatena esentutl Heaeae fessor wh as MheySce 4.This consent s for al treatments referred to above forthe same diagnosis. 5.1 have had any terms in this consent explained to me that I did not understand. These terms we oo 6. have had the opporturity to ask questions and discuss any concerns | have about the effect on my heath that | am concerned about in undergoing these procedures, 7.1 have been informed that my anonymised clinical les may be used for research and teaching purposes 8.1 have been made aware that my examinations andor treatments, received a tis clinic may be recorded for teaching ‘and assessment purposes. 9. understand that all servies/treatments are provided by a student intern under the supervision of certified practitioner 7 ve had the fees for services and treatments explained to me. Patient sgnature (or lega guardian” Incens signature» LDL Clinic Supervisor signature:- osses os (case File f- Cassidy JO otal. Risk of verebrobasiar stroke and chiropractic care. Result ofa population-based case contol and cate-cossover study November 13th, 2018 version 13 ‘Spine 2008;89:5176-$18%