Present Complaint: Have you been previously treated for this? Yes: No:

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Blake Parker
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1 Informed Consent for Acupuncture Care Present Complaint: Have you been previously treated for this? Yes: No: PLEASE READ CAREFULLY BEFORE SIGNING I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture if necessary including needling, moxibustion, cupping, electro-acupuncture, laser-acupuncture and other techniques within the scope of the practice of Traditional Chinese Medicine. These procedures would be performed by a registered acupuncturist, in accordance with the Alberta Acupuncture Regulations. I have had an opportunity to discuss with the acupuncturists and/or with other clinical personnel, the nature and purpose of acupuncture care and its procedures. I understand that results are not guaranteed. I have been advised that all insertion needles are individually packaged, pre-sterilized and disposable; therefore the risk of infection is extremely rare. I further understand and have been informed that as with all health care, in the practice of acupuncture, there are some slight risks associated with treatment, including, but not limited to, temporary soreness, bruising, blistering, minor bleeding, and temporary aggravation of symptoms, nausea and fainting. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications and I wish to rely on the acupuncturist to exercise his/her judgment during the course of my treatment, based upon the facts then known, to my best interest and benefit. I understand and acknowledge that withholding or giving false information can lead to improper treatment which that therapist cannot be held liable for. I understand that the cost of acupuncture treatment is not covered by Alberta Health and I am financially responsible to my acupuncturist for the entire treatment amount. I have read and understand the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above mentioned procedure(s). I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Confirmation of Consultation with Physician: Section 8(1) of Alberta s Acupuncture Legislation states that an acupuncturist shall not undertake the care and treatment of a person unless (A) that person has already consulted with a physician or, in the case of dental pathology, a dentist about the condition for which care and treatment from the acupuncturist is being sought; (B) that person has informed the acupuncturist that a physician or dentist has been consulted about the condition; and (C) the patient has completed a patient consultation form. Have you consulted a physician or dentist (as appropriate) about the condition for which acupuncture treatment is now being sought? Yes: No: I agree to see a physician regarding the condition(s) that I am seeking treatment for within 2 weeks of my first acupuncture treatment at Back to Health Chiropractic and Wellness Clinic: Yes: No: Signature Print Name Date Parent/Guardian Signature Print Name Date Page 1 of 8

2 Explanation of Acupuncture and Traditional Chinese Medicine Fees The purpose of this page is to clarify your financial responsibilities so we can devote our efforts to helping you get the best results in the shortest amount of time. Procedure Estimated Time Fee (Subject to change) Initial Consultation and first treatment Minutes $72.00 including GST with discussion of treatment course Child (12 years old and under) Initial 45 Minutes $70.00 including GST Consultation and first treatment with discussion of treatment course Subsequent visits including follow-up 30 Minutes (Adult) $72.00 including GST consultation, treatment and discussion of treatment course Chinese Herbs (per treatment course) Must pre-pay and may be picked up the following business day Start at $25.00 Forms of Payment: Patients are responsible for full payment at the time of services rendered. We accept cheque, interac, Visa, Master Card and cash. Any credit card arrangements and discounts must be authorized in advance. Third Party Insurance Coverage: All professional services are rendered and charged to the patient receiving care and not to an insurance provider. We will supply you with statements, or other documents for a fee, if applicable, as outlined above, to help you receive re-imbursement from a third party. Missed Appointments: with regard to any cancellation of scheduled appointments, we require at least 24 hours notice or a fee for the full cost of the scheduled appointment will be charged. Extenuating circumstances will be reviewed. Furthermore, we cannot guarantee that anyone arriving late will be run past his/her scheduled appointment time. Each patient is important to us and we have to respect the next patients schedule. If for any reason we are running late, you will be guaranteed your scheduled appointment time. I have read and understand the payment obligations as listed above. Patient/Parent/Guardian Signature Date Page 2 of 8

3 - Acupuncture Intake Form- Current Condition How long have you had this condition? What seems to be the initial cause? What seems to improve this condition? What seems to aggravate this condition? List other concurrent therapies: Do any other members of your family have this condition? Check any that apply to your family: Heart Disease: High Blood Pressure: Cancer: Stroke: Arthritis: Diabetes: Bowel Disease: Depression: Seizures: Do you have any internal pins, wires, special equipment, artificial joints (other)? (Example: pace maker, hearing aid): Y/N Are you, or are you possibly pregnant? Y/N How many weeks? Last appointment with Doctor: What medications, prescribed or otherwise are you currently taking? Have you had the experience of acupuncture before? Y/N Date: Name of Acupuncturist: Please list any major injuries, traumas, surgeries, accidents or falls, childhood illness: Page 3 of 8

4 Acupuncture Intake Form- Current Condition Have you been diagnosed with, or have you experienced any of the following? Please indicate with an X below: Circulatory/ Respiratory System: Chronic Congestive Heart Failure: Heart Disease: High Blood Pressure: Low Blood Pressure: Other Heart Condition: Varicose Veins: Phlebitis: Deep Vein Thrombosis: Easily Bruise or Bleed? Reynaud s Disease: Circulation :( e.g. Cold hands and feet): Berger s Disease: Chronic Cough: Bronchitis: Asthma/wheezing: Emphysema: Shortness of Breath: Allergies Skin: Sensitivities to oils/ lotions: Other Allergies/ Hypersensitivities: Irritated Skin Conditions (Example: Eczema/ Psoriasis): Contagious Conditions: Frostbite Lack of Sensation or Feeling Change in hair or skin texture? Dry Skin? Oily Skin? Loss of hair? Acne (Location): Other: General: Cancer/tumors: (type) Kidney Disorder: Liver Disorder: Infectious Conditions ( Example HIV, Hepatitis): STI (Sexually transmitted infection): (type): Loss of vision or hearing: Multiple Sclerosis: Parkinson s: Sciatica: Carpal tunnel syndrome: Epilepsy: Stroke(Date): Ringing in Ears: Sinus problems: Depression: Confusion: Rapid Weight Loss: Anemia: Nausea/Vomiting: Constipation: Diarrhea: Diabetes: Type Alcoholism: Tuberculosis: Polio: Lupus: Rheumatic Fever: Meningitis: whiplash: Dizziness Y/N Blood Pressure: mmhg Other: Muscles, Joints: Numbness in Limbs: _ Lower Back Pain: Difficulty Walking: Scoliosis: Osteoporosis? Arthritis: Weakness?: Swelling in Limbs: Joint Instability: Tendonitis: Restless Legs: Please Circle current symptomatic areas in the diagram below: Headaches/ Migraines: What are the triggers? Jaw Pain (TMJ) Do wear a mouth guard? Are you currently experiencing any pain? Y/N (Low-tolerable) (High- intolerable) How often do you experience this pain? Are there any other associated symptoms? How would you describe the pain? Dull; Ache; Sharp; Stabbing; Pricking; burning; Heavy; Wandering; Fixed; radiating (travels), other: What improves the pain? Heat; Cold; Pressure; Rest; Other: What aggravates the pain? Weather Changes; Stress; Menses; Other: Does the pain affect daily activities? Does the pain wake you at night? Page 4 of 8

5 Traditional Chinese Medicine Intake Form- Life Style Assessment Men Only: (Reproduction) Prostate disorder: other: Libido: Normal: Increased: Decreased: No Sexual Drive: Function: Normal: Pain: Location/ Onset: Discharge: Impotence: Premature Ejaculation: Infertility: Women Only: (Gynecology) Previous/ Present Conditions Concerning Menstruation and Reproduction: Endometriosis: PID: Fibroids: Ovarian Cysts: STI: (Type) Cancer: (Type) Yeast Infection: Frequency: Infertility (cause): other: Menses: Amenorrhea: Onset/ Duration: Birth Control Pill/ Device: First day of Last Period: Pregnant: Week: # of Pregnancies: # Normal Deliveries: AbnormalDeliveries/trauma/hemorrhage: #of Miscarriage before three months: After three months: # of Abortions: # of Premature births: Postpartum Conditions? Menopause: Age of Onset: Date of Last Menses: Menopause Symptoms (Please List): Libido: Increased: Decreased Lack of Desire: Onset/ Duration: Menstrual History (Include History even if Menses has stopped): Age at Menarche (first menstrual period): Date of Last PAP: Cycle: Regular: Irregular: Early: Late: Spotting/ Cramping between cycles: Volume: Normal: Light/ Scanty: Heavy: Onset/ Duration: Color: Normal: Light red: Bright Red: Dark red: Brown: Purple: Black: Property: Normal: Watery: Thin: Thick: Clots: PMS: Cramping/ Pain: Before Menses begins: During Menses: After Menses: Location of Pain: Severity of pain: Low (Tolerable) High (Intolerable) What Improves the Pain? Cold: Heat: Pressure: Rest: Activity: other: What Aggravates the pain? Heat: Cold: Pressure: Stress: Moods: Other: Do you experience breast tenderness: Before Menses: During Menses: After Menses: Other: Do you experience changes in moods: Anger: Worry: Anxiety: Sadness/ Crying: Do you experience other (PMS)Associated Signs and Symptoms: Forgetfulness: Clumsy: Fatigue: Dizziness: Insomnia: Headaches: Feel Faint : Nausea: Bloating: Increased Appetite: Decreased Appetite: Cravings: Sweet: Salty: Sour: Greasy: Other: Vaginal Discharge/ Leucorrhea: When (during Cycle?): Color: Odor: Vaginal Dryness/ Soreness/ Itch / Other: Page 5 of 8

6 Traditional Chinese Medicine Intake Form- Life Style Assessment Living Environment: Dry: Damp/ Humid: Cold: Hot: Preferred Food and Drink: Do you prefer any of the following? Sour: Sweet: Salty: Greasy: Spicy: Do you have any peculiar cravings? How many regular meals are you eating per day? Do you tend to skip meals? Do you eat late at night? Do you tend to eat when anxious/ stressed? Do you graze, nibble or snack? How often do you eat out in a week? Do you prefer warm temperature drinks? Do you prefer cold temperature drinks? Daily Intake: coffee: Tea (type): Fruit Juice: Soda (number of cans): Water: Alcohol: Do you smoke? Y/N Amount: Recreational Drug use (include type and frequency): Are you frequently in a state of: Fear: Worry: Anger: Sadness: Anxiety: Frustration/Irritability: What are your major sources of stress? Please Comment on your level of exercise (type and frequency): How many hours of sleep per night do you typically receive? Is your sleep interrupted? Is there any specific information regarding your lifestyle you would like to add that may aid in your treatment? Page 6 of 8

7 Do Not Write Below- Acupuncturist Use Only Traditional Chinese Medicine Symptom and Evaluation Form 1. General Energy: (Fatigue) (Feel Great) Normal: _Crash/what time of day? _ Sudden drop in energy after eating? _ Does energy level increase or decrease with exercise? _ Has concentration increased or decreased? _ General Health: Experience frequent colds and flu s Have you noticed a weight increase or decrease? 2. Fever and Chills (Exterior Signs and Symptoms-common cold/flu) Fever? _ Fever and Chills? _ Aversion to Heat? _ Chills (aversion to cold?):_duration? Sore throat? _ Sneezing? _Other: 3. Body and Limbs-Do you experience: Pain over the whole body? _Deformity of any joints? Edema/Swelling? _ Heavy sensations over the body or limbs?_ Numbness/ Tingling? _ Knee soreness and/or weakness? 4. Sweat: No sweating:_ Light Sweating: _ Heavy Sweating:_ Sweating with exertion:_ Sweating without exertion:_ Heavy sweating with high fever:_ Heavy sweating with cold limbs:_ Spontaneous sweating:_ Night Sweating:_ Sweaty palms/soles/chest (5 center):_ Sweating of specific body parts: Yellow sweat (noticeable in armpits and necklines of clothing): _ Sweating with foul odor: _ 5. Five Sense Organs: Decrease or loss of hearing (onset?): Tinnitus (ringing): _high pitch: _Low pitch:_ Ear Pain: _Discharge: Decrease or loss of sight: _Blurry vision/ floaters: _Eye pain: _ Red/itching eyes: _ Puffy: _ Discharge: Dry: Bloodshot: Dark circles: 6. Chest and Abdomen: Cough: Dry Cough:_ Phlegm:_ Scanty:_ Profuse:_ Yellow:_ Clear (white):_ Blood:_ Shortness of breath (difficulty breathing): On Inhalation: _ On Exhalation: _ At rest: _ On Exertion: _ Chest Pain or Discomfort: Burning: _ Distention: _ Pricking: _ Dull/Ache: _ Chest Fullness:_ Tightness: _ What aggravates this? Palpitations? _ How often? At night? _ Stress induced? _ Heart Rate: accelerated/regular/irregular: Hypochondriac pain? _ Gastric Pain? _ Abdominal Pain? _ Characteristic of pain? What relieves the pain/ Palpitations? Heat: _ Cold: _ Pressure: _ Bowel Movement? _Exercise/ Rest? 7. Appetite and Digestion Normal: _ Abnormal: _ Under eating: _ Over Eating: _ Easily Hungry: _ Hungry with no desire to eat: _ Belching: _ Nausea: _ Vomiting: _ Indigestion: _ Hiccups: _ Reflux: _ Heart burn: _ Bloating: _Bloating/ fullness after eating a small amount: _ Foul Breath: _Any particular taste in the mouth? (Bitter/ Bland/ Metallic) 8. Thirst: Thirsty: _ Lack of thirst: _ Drink out of habit: _ Drink a lot: _ Not wanting to drink: _ 9. Stools: Normal (considered at least 2 B.M. /day, 20 cm long): _ Frequency: Hemorrhoids: _ Constipation: _frequency: Diarrhea: _frequency: Duration: Formed:_ tired after bowel movement: _ thin and long:_ pellet- like: _ unformed: _ Loose:_ watery: _ undigested food in stool: _ blood in stools: _ black stools: _ foul odor: _ Mucous in stools: _ diarrhea at dawn: _ dry stool: _ pain when passing stool: _ burning sensation: _ diarrhea following abdominal pain:_ bearing down sensation: _ urgency/ pain (dysentery): _ incontinence: _ foul and sticky: _ alternating diarrhea and constipation: _ 10. Urination: Frequency: Normal: _ Low (6 times a day or less): _ High (more than 8 times a day): _ Increased frequency: _ Decreased frequency: _ Increased volume: _ Decreased volume: _ Onset: Function: Normal: _ Incontinence: _ Stress Incontinence: _ Hesitancy: _ Retention: _ Urgency: _ Difficulty: _ Dribbling: _ Bed wetting: _Wake to urinate: _How many times per night? _ What time?_ Pain (before urination): _ Pain (during urination): _ Burning Sensation: Color: Normal: _ Pale/ Clear: _ Dark and Yellow: _ Turbid/ Cloudy: _ Blood in Urine: _ Odor: Normal: _ Foul: _ 13. Sleep How many hours per night:_ Rested? _ Somnolence (feel sleepy) when wake up after a full night sleep: _ Constant desire to sleep/ Lethargic: _ Heavy feeling: _ interrupted? _ Insomnia: _ onset/ Duration: What time is your last meal? _ Sleepiness after eating: _Difficulty falling asleep: _Mind racing: _Anxiety: _ Panic Attacks: _ Restlessness/ toss and turn: _ Wake a lot: _ Wake easily: _ Wake early (cannot get back to sleep): _What time? Dream Disturbance: _ Nightmares: _ Vivid Dreams: _ Sexual Dreams: _ Page 7 of 8

8 Traditional Chinese Medicine Treatment Notes Tongue: Body Color: Pale:_ Pink (normal):_ Red: _ Dark Red:_ Purple: _ Bluish:_ Other: Body Shape: Enlarged body: Deep teeth marks: Slight teeth marks: Thin edges: Swollen edges: Swollen at Root: Depressed Root: Swollen in center: Swollen tip: Deviated: Quiver: Cracks: Ulcerations: Stasis Spots: Sublingual Veins: Tongue Coating: Thin: _ Normal: _ Thick: _ Greasy: _ Wet/Watery: _ Dry: _ White: Yellow: Slight Yellow: Peeled: _ At Root: _ At Middle: _At Tip: _ Mirrored: _ Tongue Picture: Other: Pulse: Speed: 5 beats per breath (Rapid): 4 beats per breath (Normal): 3 beats per breath (Slow): Depth: Superficial (Exterior): _ Middle (Internal Syndrome): _ Deep (Internal, chronic, severe): _ Overall Quality:(Shape/Strength):Superficial/Floating, Bounding, Soft, Deep, Hidden, Firm, Weak, Slow, Unsmooth, Rapid, Thin, Intermittent, Short, Slippery/Soggy, Tight, Wiry, Long Left (Yin Blood): Ht/Si: Lr/ Gb: Ki Yin/ Ub: Right (Yang Qi): Lu/Li: Sp/ St: Ki Yang/ Ub: Child: Finger Vein: Differentiation of Syndrome (8 Principles): Yin/ Yang Interior/ Exterior Heat/ Cold Deficiency/ Excess Organ Systems affected: Condition of: Qi, Blood, Body Fluids: Diagnosis (Syndrome): Treatment Principle: Other Recommendations: Page 8 of 8

Patient Intake Form for Acupuncture Treatment at Infinite Healing

Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age: