GENERAL INTAKE FORM

Date:__________________

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

 

PERSONAL INFORMATION        

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

 

LIFESTYLE

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):

__Massage

__Physiotherapy

__Osteopathy

__Naturopathic Medicine

__Chiropractic

__Craniosacral

__Acupuncture

__Other (specify: ______________

 

MEDICAL HISTORY

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.


 

SKIN & HAIR

__Rashes

__Itching

__Eczema

__Psoriasis

__Boils/Cysts

__Acne

__Hives

__Warts

__Dryness

__Colour changes

__New/Changed moles

__Lumps

__Dandruff

__Hair loss

__Change in hair texture

__Nail changes

__Other (specify:________)

 

EYES

__Impaired vision

__Glasses/contacts

__Far-sighted

__Near-sighted

__Double vision

__Colour blindness

__Night blindness

__Sensitivity to sun

__Pain

__Redness
__Itching

__Dryness

__Discharge

__Blurring

__Excessive tearing



 

__Spots/Floaters

__Blind spot

__Glaucoma

__Cataracts

__Other (specify:_______)

 

EARS

__Ringing/ Tinnitus

__Discharge

__Pain/Aches

__Deafness

__Infections

__Wax build-up

__Ear tubes

__Other (specify: _______)

 

NOSE & SINUSES

__Allergies

__Loss of smell

__Post nasal drip

__Nosebleeds

__Dryness

__Sinus infections

__Sinus pain

__Nasal congestion

__Sleep apnea

__Snoring

__Nasal Polyps

__Other (specify: _______)

 

MOUTH & THROAT

__Dental cavities

__Mercury fillings

__Gum problems

__Grinding/Clenching

__Ulcers/sores

__Loss of Taste

__Pain/Soreness

__Frequent sore throat

__Hoarseness

__Tonsillitis

__Phlegm/Mucous

__Cold sores

__Enlarged glands

__Jaw pain/clicking

__Facial pain/tics

__Other

 

HEAD & NECK

__Headache

__Migraines

__Injury

__Lumps

__Swollen glands

__Swollen lymph nodes

__Goitre

__Pain/stiffness

__Other

 

RESPIRATORY

__Cough

__Sputum

__Coughing blood

__Wheezing

__Asthma

__Bronchitis

__Pneumonia

__Emphysema

__Tuberculosis

__Difficulty

__Shortness of breath (SOB)

__SOB lying down

__SOB at night

__Other (specify: _______)

 

CARDIOVASCULAR

__High blood pressure

__Low blood pressure

__Irregular heart beat

__Fast heart beat

__Slow heart beat

__Palpitations
__Murmurs

__Angina

__Chest pain

__Swelling of limbs

__Cold hands or feet

__Thrombophlebitis

__Blood clots

__Varicose veins

__Elevated cholesterol

__Past ECG test

__Other heart tests

__Other (specify: _______)

 

BLOOD & LYMPHATIC
__Anemia

__Easy bruising/bleeding

__Slow clotting

__Fatigue/weakness

__Pallor (paleness)

__Swollen lymph nodes

__Past transfusions

__Other (specify: _______)



 

 breathing

__Pain with breathing








 

INFORMED CONSENT

 

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

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