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Thank you for taking the time to fill out the requested information.  Everything disclosed is confidential.



Name: __________________________Date of Birth (dd/mm/yy): ________________

Address: _________________________________________________________________________

                        Street / City / Province / Postal Code

Home phone: _______________________ Cell phone:___________________________ E-mail: ____________________________________

Occupation: ________________________  Marital status:  S M D W Sep


How did you find out about us? _______________________________________________________

Were you referred by a healthcare practitioner? __________________________________________

What are your top three reasons for coming today?

1) ________________________________________________________

2) ________________________________________________________

3) ________________________________________________________

How much change in diet and lifestyle are you willing to make to improve this condition?  

none / a small amount / a great amount



How many cups per day do you drink on average of the following?

Coffee_______ Tea_______ Milk ______ Herbal tea______ Alcohol______ Water_______ Juice_______ Soda________

What alcoholic beverages do you drink? _________________________

How often? ______________________

Do you smoke?______           If so how many per day?_______

Do you smoke or consume canabis?  ______  If so, how much? _______

What do you do for exercise, recreation and relaxation?     __________________________________________________________________________


Note therapies used presently (√) or in the past (P):




__Naturopathic Medicine




__Other (specify: ______________



List any medications or nutritional supplements that you are currently taking:

Medication / Nutritional Supplement             Used for?             For how long?






Do you have any physical pain or discomfort at this time?     Y  /  N

If yes, please indicate where:

                                          Right      Left           Left      Right


Have you undergone any surgeries in the past?    Y  /  N


If yes, give the reason: _____________________________________________________________________________


Have you suffered any injuries requiring medical care in the past 5 years?   Y / N


If yes, list the injury/injuries: _____________________________________________________________________________


Do you have internal pins, wires, artificial joints, or other implants in place?   Y / N


If yes, list: _____________________________________________________________________________


Are you allergic or hypersensitive to anything?   Y / N

If yes, list: _____________________________________________________________________________


Are you currently pregnant, or is there a chance that you may be pregnant? Y / N _____________________________


Have you recently experienced any loss of body sensation or balance? Y/N

If yes, list and explain: _____________________________________________________________________________


Are you currently being treated by a health care practitioner/medical doctor?  Y / N

If yes, you are being treated for: _____________________________________________________________________


Practitioner/Dr.: ____________________ City: __________________Province: ______



I verify that the information given on this form is true and accurate. I acknowledge that I am receiving TCM therapy and that my record may be used for informational purposes. I acknowledge that my clinic file may not be used for insurance claims or for the intent of representing a medical authority. I acknowledge that I may or may not be reimbursed by my insurance company, but am responsible for payment regardless.  I also acknowledge that it is my responsibility to update my treatment file and advise the therapist of any changes in my health status.


Signature:  _________________________ Date: ______________________________


Emergency Contact:  ___________________Telephone:  _______________________


Please place a checkmark (Y) next to any of the following symptoms that you currently experience and a (P) next to any that you have had in the past.












__Colour changes

__New/Changed moles



__Hair loss

__Change in hair texture

__Nail changes

__Other (specify:________)



__Impaired vision




__Double vision

__Colour blindness

__Night blindness

__Sensitivity to sun






__Excessive tearing



__Blind spot



__Other (specify:_______)



__Ringing/ Tinnitus





__Wax build-up

__Ear tubes

__Other (specify: _______)




__Loss of smell

__Post nasal drip



__Sinus infections

__Sinus pain

__Nasal congestion

__Sleep apnea


__Nasal Polyps

__Other (specify: _______)



__Dental cavities

__Mercury fillings

__Gum problems



__Loss of Taste


__Frequent sore throat




__Cold sores

__Enlarged glands

__Jaw pain/clicking

__Facial pain/tics








__Swollen glands

__Swollen lymph nodes








__Coughing blood








__Shortness of breath (SOB)

__SOB lying down

__SOB at night

__Other (specify: _______)



__High blood pressure

__Low blood pressure

__Irregular heart beat

__Fast heart beat

__Slow heart beat



__Chest pain

__Swelling of limbs

__Cold hands or feet


__Blood clots

__Varicose veins

__Elevated cholesterol

__Past ECG test

__Other heart tests

__Other (specify: _______)



__Easy bruising/bleeding

__Slow clotting


__Pallor (paleness)

__Swollen lymph nodes

__Past transfusions

__Other (specify: _______)



__Pain with breathing




Acupuncture is a treatment involving the insertion and manipulation of fine stainless steel needles in specific points of the body to relieve certain ailments and improve general health.


Cupping is the use of suction cups to reduce pressure and draw the skin and superficial tissue into the device in order to relieve pain and stasis by promoting proper blood circulation.


Electroacupuncture is the use of a small electric current between pairs of needle points to treat pain and to restore health and wellbeing by reducing inflammation and increasing blood flow.


Moxibustion is the application of indirect heat by utilizing moxa sticks to stimulate circulation around joints and articulations.


Heat Therapy by use of heat lamps (infrared or otherwise) or warming pads is the application of heat to relieve pain and contribute to general health.


Some possible minor side effects include:

  • Mild bruising or pain at needle site

  • Temporary aggravation of pain or symptoms

  • Feeling faint or dizzy (possible result from fear or apprehension)

  • Feeling tired or lightheaded


Some very uncommon, but serious complications include:

  • Bacterial infections

  • Pneumothorax (or collapsed lung) from needle inserted too deeply, entering the chest cavity.

  • Nerve damage

  • Needle breakage requiring surgical removal

  • Kidney damage

  • Brain damage or stroke

  • Haemopericardium (damage to pericardium, heart’s membrane)


I, the undersigned, have read and understood the above terms. I hereby give my voluntary consent for the administration of therapy, which may include, but is not limited to, acupuncture, cupping, electroacupuncture, moxibustion and heat therapy. 

I understand the risks involved and all relevant questions and concerns have been answered.


Cancellation Policy

If you need to cancel your appointment please call us at (613)400-6284 at least 24 hours in advance.  Since we turn away other clients to hold your reservation any cancellations with less than 24 hours notice we will have to charge a $50 cancellation fee.


 __________________________ _______________                   _____________________________

  Print Name             Date             Signature

Thanks for submitting!

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