Updated: 060112

MeditechBioflexLowlevelLaserPATIENTINFORMATIONSHEET

Name:___________________________________________ Sex:M/F Date:________________Address:_________________________________________City:_______________Province:_________PostalCode:_________HomePhone#:_____________________ WorkPhone#/Other#:____________________EMAIL:_________________________ Dr.’sName&Ph.#:________________________DateofBirth:______________________ Howdidyouhearaboutus?___________________________________________________________________________________

CurrentHealthHabits Yes No PatientsComments Doctor’sComments

Did/doyousmoke? Did/doyoudrinkanyalcohol? Areyouconcernedaboutyourdiet? Haveyoubeeninaccidents? Currentmedications?HowLong? Allergies? Exerciseregularly? Sleepingpostureosideostomachoback Females:Areyoupregnant? Did/doyouhavecancer?Type?

Isthereafamilyhistoryof: HeartDiseaseoArthritisoCanceroDiabetesoOther_________PresentComplaint:___________________________________________________________________________Painorproblemstartedon________________________________Painsare: Sharpo Dullo Constanto IntermittentoWhatactivitiesaggravateyourcondition/pain?________________________________________________________Whatactivitieslessenyourcondition/pain?___________________________________________________________Isconditionworseduringcertaintimesoftheday?_____________________________________________________Isthisconditioninterferingwithyour: Work?____ Sleep?____ DailyRoutine?____ Other?____Isconditiongettingprogressivelyworse?_____________________________________________________________HaveyouseenanyotherDoctorsforthiscondition?____________________________________________________Anyeffectivetreatments?__________________________________________________________________________Haveyouexperiencedanysideeffectsfromthedrugsandsurgeries?______________________________________OtherSymptoms:

o Headaches o Fatigueo VisualDisturbances o Depression/Anxietyo SleepingProblems o MemoryLosso BackPain o FaintingEpisodeso FeelingsofStress o LossofSmello Irritability o LossofTasteo ChestPain o GastrointestinalDisturbanceso PinsandNeedlesSensations o Ataxiao NumbnessandTingling o Tinnituso ShortnessofBreath o

Updated: 060112

PATIENTPAINASSESSMENT

Name:___________________________________________________________ __________________Last First Date

0-10NumericPainIntensityScale(1)

No Mild Moderate SevereVery IntolerablePain Pain Pain Pain Severe Pain1)PleaserateyourpainbycirclingtheonenumberthatbestdescribesyourpainatitsWORSTinthepast24hours.

0 1 2 3 4 5 6 7 8 9 10NoPain IntolerablePain 2)PleaserateyourpainbycirclingtheonenumberthatbestdescribesyourpainatitsLEASTinthepast24hours.

0 1 2 3 4 5 6 7 8 9 10NoPain IntolerablePain 3) PleaserateyourpainbycirclingtheonenumberthatbestdescribesyourpainontheAVERAGE.

0 1 2 3 4 5 6 7 8 9 10

NoPain IntolerablePain 4) PleaserateyourpainbycirclingtheonenumberthattellshowmuchpainyouhaveRIGHTNOW.

0 1 2 3 4 5 6 7 8 9 10NoPain IntolerablePain 5)Whattreatmentsormedicationsareyoureceivingforyourpain?________________________________________________6)Circletheonenumberthatdescribeshow,duringthepast24hours,painhasinterferedwithyour:A.Generalactivity

0 1 2 3 4 5 6 7 8 9 10DoesnotInterfere CompletelyInterferes

B.Walkingability

0 1 2 3 4 5 6 7 8 9 10DoesnotInterfere CompletelyInterferes

C.Normalwork(includesbothworkoutsidethehomeandhousework)

0 1 2 3 4 5 6 7 8 9 10DoesnotInterfere CompletelyInterferes

D.Sleep

0 1 2 3 4 5 6 7 8 9 10DoesnotInterfere CompletelyInterferes

E.Enjoymentoflife

0 1 2 3 4 5 6 7 8 9 10DoesnotInterfere CompletelyInterferes

0 1 2 3 4 5 6

7 8 9 10

Updated: 060112

CONSENTTOLOWINTENSITYLASERTREATMENT

LowIntensityLaserTherapy(LILT)consistsoftheuseofmonochromaticlightemissionfromaLowIntensityLaserDiode(250milliwattsor less)oranarrayofhigh intensitySuperLuminousDiodes(providingopticalpower inthe1000-2000milliwattrange)totreatmusculoskeletalinjuries,chronicanddegenerativeconditionsandtohealwounds.Thelightsourceisplacedin contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellularbiomolecules resulting in the restorationofnormal cellmorphology, functionand theenhancementof thebody’shealingprocesses.LowIntensityLaserTherapyimproves/curesmultiplepathologieswiththefollowingobjectivesinmind,i.e.:

1. Eliminationofpain.2. Reducingorobviatingdependenceonpharmaceuticals.3. Restorationofmobility(normalrangeofmotion).4. Improvequalityoflife(activitylevels,sleep,etc.)5. Removetheneedforsurgicalinterventioninmanysituations.

Treatments are usually scheduled 2-3 times per week or more frequently in acute cases, at least initially. Subsequenttreatmentsarescheduledinaccordancewiththepatient’sphysicalstatus.Withregardtothenumberoftreatmentsessions,thesemayvaryfrom1to30.Aminimumof5treatmentsisrecommended.Itisimportanttobeawarethatbeforetreatmentis initiated that the exact number of treatments cannot be predicted. In most cases we expect to see some change insymptomologyafter3-5sessions.Therearehoweverexceptionstothisrule.Acute injuriesgenerallyrespondmorerapidlythanchronicproblemsandeachindividual’stissueresponsevaries.Pleasedonotforgetthatourobjectiveistominimizethelength of treatment and the number of visits. On occasion, however, even our best efforts requiremultiple treatments,patienceandtime.The risk of complications from LILT treatment is substantially less than that associated with many other treatments,medications,andproceduresavailable for thesameconditions. It is thepracticeofour institution to informpatientswithregard to these and other matters. Some patients have experienced exacerbation of pain or fatigue subsequent totreatment.Ifthisoccurs,utilizepainmedication,and/oriceontheareaofinvolvementandnotifythedoctor/therapistpriortothenexttreatment.Theexistenceofthisphenomenonisduetoasensitivetissueresponseandprotocolswillbeadjustedaccordinglyonyournextvisit.Adullachingsensationsubsequenttotreatmentlastinglessthan24hoursindicatesthatyourtissuesarereactingpositivelyonthecellularlevel.Contraindicationstotreatmentinclude:firsttrimesterofpregnancyandpatientsonphoto-sensitivemedications.Laserdoesnotcausecancer,hasnocytogeniceffectanddoesnotdamagetissues.I acknowledge that I have discussed, or I have had the opportunity to discuss, withmy doctor the nature, purpose andproceduresofLILTtreatmentingeneral,mytreatmentinparticular,alternativetreatmentsandprocedures,materialrisksofthosetreatmentsandprocedures,thecorrespondingfeescheduleaswellasthecontentsofthisconsentform.Iunderstandthatmyclinicalinformationmaybeusedaspartofaclinicalstudy.Iherebygivemyfullconsentandpermissiontousethisinformationsolelyforthepurposestated.Iconsenttothelowintensitylasertreatmentsofferedorrecommendedtomebymydoctor.Iintendthisconsenttoapplytoallmypresentandfuturelowintensitylasertreatments.

____________________ ______________________________ _______________________________Date PatientSignature/LegalGuardian GuardianRelationshiptoPatient

_______________________________PrintedName

Updated: 060112

PATIENTCOMPLIANCE–THERAPEUTICIMPLICATIONSAtthistime,wewishtoemphasizeanumberoffactorsregardingtheadministrationofLaserTherapy.Thetherapyteamthatattendstoyourmedicalproblemswilladviseyouregardingthefrequencyanddurationoftreatments.Thismayvaryfromonepatienttoanotherandalsowithrespecttotheconditionbeingtreated.Fortravelandworkreasonsdeviationsfromthetreatmentschedulearepermissible.Generally,however,patientsareadvisedtofollowthecourseoftreatmentoutlined,inordertoproduceoptimalclinicaloutcomes.Significantdeviationfromthatcoursecanimpedethehealingprocess.Ourexperienceoverthecourseofalmosttwentyyearshasprovenconclusivelythatpatientswhocomplywiththeirprescribedtherapeuticscheduleachievetheirobjectivesmorerapidlythanthosewhodonot.Onceagain,inordertoachievemaximumbenefit,patientsmustbeencouragedtofollowthetreatmentscheduleoutlinedbythehealthcareprofessionalmanagingtheircase.

• Allowanceswithregardtofrequencyoftreatmentsmaybemadedependingongeographicconsiderationsandthetimefactorinvolved.Forbestoutcomeshowever,arelativelystructuredtherapeuticprogrammeisessential.

• Insomepatients,improvementmaybeevidentafteronly1-2treatmentsessions,inothershowever,secondarytogeneticfactors,chronicity,etc.8-12treatmentsmayberequiredbeforesignificantimprovementisexperienced.

• Itisalwaysstressedthatpatientsshouldadheretotheprogrammerecommended,inordertoachievethedesiredobjective.

• AdverseeffectsresultingfromLaserTherapyarenegligibleandarenotsignificantinourextensiveexperience.Nevertheless,ifanyshouldoccurbringthemtotheimmediateattentionofthemedicalstaffinorderthatthetherapymaybemodifiedaccordingly.

• Itisessentialthatpatientsbereassessedbythehealthcareprofessionaldirectingtheirtherapeuticprogrammeevery2-4visits,toeffectprotocolchangesthatwilladvancethehealingprocess.

• CustomizationoftheprotocolsforeachindividualpatientisanimportantaspectofLaserTherapy.

• Ifpatientsneedtobeseenmorefrequentlybythesupervisingclinician,theyshouldsoindicatewhenregisteringornotifytheattendingtherapist,priortotheinitiationoftreatment.

FredKahn,M.D.,F.R.C.S.(C)