Acupuncture Health History Form Date of first appointment:

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Shana Robinson
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1 Acupuncture Health History Form Date of first appointment: Please print, fill out and bring to your first appointment Name (Last) (First) PHN: Date of Birth (M/D/Y) Male/Female Address City: Province: Postal Code Phone number (H) (W) (C) Employer/Occupation Family doctor: Referred by: address Emergency Contact Name Relationship Emergency Contact phone number (H) (W) (C) Are you being treated by any other health practitioners? Have you received massage before? Y N Do you smoke? Y N Are you currently pregnant? Y N Have you consumed any alcohol or pain meds in the last 12 hours? Y N Please indicate: What is your Primary Concern? Have you consulted your primary care practitioner about this concern? Y N When did it begin? Has it changed? How so? What makes it better? What makes it worse? Do you experience pain, numbness or itch? Where? Please indicate on chart How would you describe your pain (e.g. burning, dull ache, sharp, moving)? Please mark your current level of pain: 0/ /10 Please mark your current level of stress:0/ /10 Please mark your current level of activity: 0/ /10 Please mark your current level of energy: 0/ /10 Please mark your current level of mental clarity: 0/ /10 Page 1 of 6

2 Do you perform cardio exercise? Y N Do you perform strengthening exercises? Y N Do you stretch? Y N During exercise, do you experience dizziness, headaches, difficult breathing, chest pain, extreme muscle soreness or weakness? Y N Please indicate: Do you experience vivid dreams or nightmares? Y NWhat time do you go to bed? What time do you fall asleep? What time do you wake up? Do you wake during the night? Y N When? Do you awake in the morning feeling refreshed? Y N How many servings do you consume in a day? Water Coffee/tea Alcohol How would you describe your diet? Do you experience cravings? For what? Are you sensitive to any foods? Do you prefer warm drinks or cold drinks? Do you ever experience acid reflux, heartburn, flatulence, bloating, burps, nausea, vomiting, indigestion, or abdominal pain, etc.? Do you tend to feel warm/over heated/cold? Y/NWhen do you sweat? What is your favourite weather? Your least favourite weather? Do you ever experience: anxiety, panic, stress, anger, grief, fear, depression, frustration, irritation, mania, an inability to turn off your brain, etc.? Please list any allergies you have (include symptoms you experience): Please list any surgeries or traumatic injuries you have experienced: Please list any medications/herbs/supplements/vitamins you are currently taking, and your reason for taking them: Page 2 of 6

3 Have you everexperienced symptoms or sought treatment for conditions of the following systems (Please describe): Brain/nerves: Psychological/emotional: Eyes/ears/nose/throat: Lungs: Heart: Liver: Kidney: Digestion: Obstetrics/gynecology: Blood: Auto/Immunity: Bones/muscles/joints: Skin: Eyes: Teeth/gums: Infectious diseases: Other: Gynecological - Have you ever experienced: O clotted menses O vaginal sores O vaginal discharge O breast lumps O scanty periods O menopause O irregular periods O painful periods O fibroids Ocysts O endometriosis O other O Flow Description (colour, consistency, volume) O Most Recent Menses O Duration of Menses O Age of First Menses O Birth Control Type O How long have you been using it? O Date of most recent pap smear O Currently Pregnant? Y N O Currently Nursing? Y N O Number of Pregnancies O Number of Births O Number of miscarriages/abortions O Number of premature births O Difficult pregnancy Page 3 of 6

4 Do you experience or have you ever experienced (please check all that apply): Ocolour blindnessospots/floaters in eyesocataractsoblurry visionosore/red/burning/itchy eyesonight blindnessosensation of a lump in throatosore throatodry mouth or throatofrequent clearing of throatocopious salivao swollen glandso sores on lips or tongueodizzinessonose bleedsogrinding teethofacial pain or paralysisomigraines/headacheosinus issuesobitter taste in moutho metallic taste in moutho low-pitch ringing in ears O high-pitch ringing in ears O poor hearing O earaches Omucous/phlegm(colour: )Odifficulty breathing O asthma O coughoheart palpitations or irregular heart beatolow blood pressureofaintingochest pain or tightnessocold hands or feetodifficult breathingoedemaoswelling in hands/ankles/feetopoor circulationo joint pins or replacementsodry skin O brittle or bendy nailso easy bruisingoother How often do you urinate/day? What colour does your urine tend to be? How often do you have a bowel movement? Do you ever use laxatives? What types? Have youconsulted with a physician or other primary care providerabout the condition for which acupuncture treatment is now being sought? Yes No The information I have provided on this health history form is true and complete to the best of my knowledge. Client name: Client/Guardian signature: Page 4 of 6

5 Acupuncture Consent Form (Please read prior to your first appointment, and then sign in the presence of the Acupuncturist) Description of Traditional Chinese Medicine therapies and possible side effects: Acupuncture: Involves the insertion of fine, sterile, disposable needles through the skin to effect changes in the tissues, physiological systems, meridians and acupuncture points. It is a gentle procedure, performed by a trained professional, and every care will be taken to ensure comfort and safety, but it is possible for the recipient to experience mild burning or tingling pain upon insertion. Other rare side effects are not limited to, but can include bleeding, bruising, hematoma, nausea, fainting, and post-treatment discomfort or drowsiness. Extremely rare side effects can include infection, shock, convulsions, possible perforation of internal organs, stuck or bent needles, and worsening of symptoms. It is important to inform the therapist of any discomfort you are experiencing so that needles can be adjusted or removed. It is also important to inform the Acupuncturist of any dizziness, nausea or light headedness that occurs during or after an acupuncture treatment. Only pre-sterilized, single use needles will be used in the treatments. All needles are immediately and safely disposed of after each treatment. Cupping: This is a technique that involves localized suction produced by heating the inside of a small glass cup. There is a possibility of local bruising from the suction. Very rarely, a slight burn or blister may happen due to the heat. Tui-Na: Tui Na refers to traditional Chinese massage techniques including pressing, rubbing, kneading and pinching to help bring body into balance. The techniques are applied to the tissues and points of the acupuncture system. Manipulating the body with these methods locally promotes blood flow and removes blood stasis. It is possible for the techniques to lead to bruising or mild discomfort. Ear acupressure: In this technique, small seeds are taped to acupoints on the ear. The seeds typically stay on the ear for 3-5 days. The pressure from the seeds can be quite painful. The seeds can be removed at any time. If itchiness or rash occurs on the ear, the tape and seeds should be removed immediately. Heat treatment/tdp lamp: TDP lamps (infrared heat) and heating pads are used to warm areas of the body. Typically, the treatment is warm and comforting. Every precaution is taken to prevent overwarming, but there exists the slight possibility of a slight burn. Moxibustion: Traditional Moxa therapy utilizes the burning of rolled mugwort herb above acupuncture points to warm the points and local areas. In this clinic, an electric moxa pen is used to create the same effect. Treated areas tend to be left pink and feeling warm. The treatment is safe, but there exists the possibility of overheating and slight burns. Page 5 of 6

6 By signing this form, I acknowledge that: I have read the descriptions, and potential side effects, of the Traditional Chinese Medicine modalities available at this clinic as presented on the previous page; Traditional Chinese medicine also includes various other techniques. Any other techniques, their benefits and their precautions will be discussed with me at the time that they are being considered; I consent to treatment by the Acupuncturist, for the purposes noted on my health history form, including assessments, examinations and techniques which may be recommended by the Acupuncturist. I may refuse the use of any technique at any time; I understand that the Acupuncturist is providing acupuncture services within their scope of practice as defined by the College and Association of Acupuncturists of Alberta. The Acupuncturist will do everything possible to ensure a safe and comfortable treatment experience; I acknowledge that the Acupuncturist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that this therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks, and those risks have been explained to me. I assume those risks; I acknowledge and understand that, in order to determine the best course of treatment and to best avoid side effects, the Acupuncturist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by the Acupuncturist and disclosed to the Acupuncturist all of those medical conditions affecting me. It is my responsibility to keep the Acupuncturist updated on my medical history. The information I have provided is true and complete to the best of my knowledge; I authorize the Acupuncturist to release or obtain information pertaining to my condition(s) and/or treatment to/from other caregivers or third party payers; I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment/s as proposed by the Therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped. Client Name Client/GuardianSignature Witness Date signed Page 6 of 6

Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:

Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name