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) ________________________________________________________
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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:
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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:
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Mild bruising or pain at needle site
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Temporary aggravation of pain or symptoms
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Feeling faint or dizzy (possible result from fear or apprehension)
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Feeling tired or lightheaded
Some very uncommon, but serious complications include:
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Bacterial infections
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Pneumothorax (or collapsed lung) from needle inserted too deeply, entering the chest cavity.
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Nerve damage
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Needle breakage requiring surgical removal
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Kidney damage
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Brain damage or stroke
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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.
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