acupuncture Essentials consultation form Date of Consult: ______/_____/______ Name: __________________________________________________ Month/ Day /Year Home Ph#:(______)______________________________________ DOB:_____/_____/____________ Age: ________ Work Ph#: (______)______________________________________ Cell Ph#: (______)______________________________________ Month/ Day Height: ____________ Street Address: __________________________________________ City: _______________________ Postal Code: ________________ e-mail address: __________________________________________ HOW DID YOU HEAR ABOUT OUR CLINIC? ☐ FRIEND ☐ FAMILY ☐ DOCTOR ☐ INTERNET ☐ ADVERTISEMENT ☐OTHER:________________________ 1._________________________________________________________________________________ 2. ________________________________________________________________________________ 3. ________________________________________________________________________________ OPERATIONS AND HOSPITALIZATIONS: DIAGNOSIS PROCEDURE CURRENT MEDICATIONS/SUPPLEMENTS: NAME DOSE/FREQUENCY REASON ALLERGIES: DRUG OR SUBSTANCE Weight: ____________ NOTES: Office Use Only PRIMARY CONCERNS/COMPLAINTS: DATE /Year REACTION 1 acupuncture Essentials consultation form NOTES: Office Use Only FAMILY HISTORY: CHECK IF APPLICABLE MOTHER FATHER BROTHER SISTER CHILD GENERAL HEALTH ☐ GOOD ☐ GOOD ☐ GOOD ☐ GOOD ☐ GOOD ☐ POOR ☐ POOR ☐ POOR ☐ POOR ☐ POOR ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ HYPERTENSION ☐ HYPOTENSION ☐ ☐ ☐ ☐ ☐ STROKE: ☐ ISCHEMIC ☐ ☐ ☐ ☐ ☐ EPILEPSY ☐ ☐ ☐ ☐ ☐ MENTAL ILLNESS ☐ ☐ ☐ ☐ ☐ TUBERCULOSIS ☐ ☐ ☐ ☐ ☐ OTHER:_______________________ ☐ ☐ ☐ ☐ ☐ _______________________ ☐ ☐ ☐ ☐ ☐ CANCER DIABETES ☐ TYPE I ☐ TYPE II ☐ HEMORRHAGIC MEDICAL HISTORY: ☐ AIDS/HIV ☐ emphysema ☐ MS ☐ ischemic stroke ☐ gastritis ☐ alcoholism ☐ epilepsy ☐ mumps ☐ hemorrhagic stroke ☐ IBS ☐ appendicitis ☐ goiter ☐ pacemaker ☐ hypothyroid ☐ anemia ☐ arteriosclerosis ☐ gout ☐ pleurisy ☐ hyperthyroid ☐ mononucleosis ☐ asthma ☐ heart disease ☐ pneumonia ☐ tuberculosis ☐ bronchitis ☐ birth trauma ☐ hepatitis ________ ☐ polio ☐ typhoid fever ☐ osteo-arthritis ☐ cancer ☐ hypertension ☐ rheumatic fever ☐ ulcers ☐ enteritis ☐ chicken pox ☐ hypotension ☐ scarlet fever ☐ whooping cough ☐ rheumatoid arthritis ☐ diabetes ☐ measles ☐ seizures ☐ colitis 2 acupuncture Essentials consultation form NOTES: Office Use Only LIFESTYLE: ☐ alcohol, _____(#)/week ☐ marijuana, ____/day ☐ other:_____________________ ______/day ☐ tobacco, _____(#)/day ☐pop, _______(#)/day exercise: ☐ yes ☐ no. ________times/week ☐ family stress ☐ work stress type:__________________________________ DIETARY INFORMATION: ☐ poor appetite ☐ normal appetite ☐ bitter taste in mouth ☐ excessive appetite ☐ metal taste in mouth ☐ other cravings:____________________________ ☐ no thirst ☐ very thirsty ☐ crave sweet ☐ sweet taste in mouth ☐ crave salt ☐ sour taste in mouth ☐ other taste in mouth:____________________ ☐ normal thirst glasses of water(juice) ______/day AVERAGE DAILY MENU: BREAKFAST ___________________________________________________________________________ ___________________________________________________________________________ SNACK ___________________________________________________________________________ ___________________________________________________________________________ LUNCH ___________________________________________________________________________ ___________________________________________________________________________ SNACK ___________________________________________________________________________ ___________________________________________________________________________ SUPPER ___________________________________________________________________________ ___________________________________________________________________________ SNACK ___________________________________________________________________________ ___________________________________________________________________________ SLEEP: ☐ insomnia ☐ problems staying asleep ☐ dream disturbed sleep ☐ troubles falling asleep ☐ wake up tired ☐ nightmares 3 acupuncture Essentials consultation form NOTES: Office Use Only CARDIOVASCULAR: ☐ high blood pressure ☐ lightheaded ☐ fast heartbeat ☐ orthostatic hypotension ☐ low blood pressure ☐ chest pain ☐ palpitations ☐ phlebitis ☐ fainting ☐ slow heartbeat ☐ irregular heart beat ☐ heart attack GASTROINTESTINAL: ☐ nausea ☐ diarrhea ☐ undigested food in stools ☐ hemorrhoids ☐ vomiting ☐ constipation ☐ IBS (irritable bowel syndrome) ☐ gastritis ☐ acid regurgitation ☐ laxative use ☐ stomach cramps ☐ enteritis ☐ gas ☐ black stools ☐ itchy anus ☐ hard stools ☐ hiccup ☐ blood in stools ☐ burning anus ☐ bloating after meals ☐ mucus in stools ☐ rectal pain ☐ bad breath ☐ intestinal cramping ☐ ulcerative colitis ☐ gurgling sounds ☐ loose stools _____(#) bowel movements/day HEAD, EYES, EARS, NOSE, THROAT: ☐ glasses ☐ blurred vision ☐ TMJ ☐ excessive saliva ☐ nose bleeds ☐ eye strain ☐ night blindness ☐ gum disease ☐ sinus problems ☐ tinnitus ☐ red eyes ☐ glaucoma ☐ sore gums ☐ clear throat often ☐ poor hearing ☐ itchy eyes ☐ cataracts ☐ bleeding gums ☐ recurrent sore ☐ earaches ☐ spots in eyes ☐ grinding teeth ☐ sores on lips ☐ swollen glands ☐ headaches ☐ “floaters” in vision ☐ soft teeth ☐ sores on tongue ☐ lumps in throat ☐ migraines ☐ poor vision ☐ cavities ☐ dry mouth ☐ goiter ☐ concussions throat 4 acupuncture Essentials consultation form RESPIRATION: Notes: Office Use Only ☐ short of breath ☐ tightness in chest ☐ chest oppression ☐ difficulty breathing lying down ☐ asthma/wheezing ☐ dry cough ☐ chronic cough ☐productive cough with: ☐ a lot of sputum, ☐ little sputum, ☐ clear sputum, ☐ sticky sputum, ☐ green sputum, ☐ blood in sputum SKIN AND HAIR: ☐ rashes ☐ eczema ☐ dandruff ☐ premature grey hair ☐ hives ☐ psoriasis ☐ itchy skin ☐ alopecia/hair loss ☐ ulcerations ☐ shingles ☐ fungal infections ☐ brittle hair ☐ dry skin ☐ oily skin ☐ acne GENITO-URINARY: ☐ painful urination ☐ cloudy urination ☐ scanty urination ☐ frequent urination ☐ dark yellow urine ☐ urination at night ☐ copious urination ☐ light yellow urine ☐ burning urination ☐ urinary incontinence ☐ clear urine ☐ retention of urine ☐ frequent bladder infections ☐ frequent kidney infections NEUROPSYCHOLOGICAL: ☐ seizures ☐ tics ☐ anxiety ☐ abuse survivor ☐ trigeminal neuralgia ☐ numbness ☐ poor memory ☐ irritability ☐ ADHD ☐ bell’s palsy ☐ tingling ☐ depression ☐ easily stressed ☐ parkinson’s ☐ fainting KEY: O = pain, X = tingling, ● = numbness, ✓ = tics, ➔ = pain radiates in this direction 5 acupuncture Essentials consultation form MALE SEXUAL HISTORY: Notes: Office Use Only ☐ erectile dysfunction ☐ premature ejaculation ☐ genital warts/condyloma ☐ prostatitis ☐ testicular trauma ☐ genital herpes ☐ low libido ☐ wet dreams ☐ dizzy/tired after ejaculation ☐ high libido frequency of intercourse _______x/week/month ☐ Sexually Transmitted Disease History: ____________________________________________________ OTHER MALE SPECIFIC HISTORY: ☐ varicocele (repaired ☐) ☐ history of steroid use ☐ hernia (repaired ☐) ☐ cancer/chemotherapy treatment ☐ exposure to pesticides/chemicals FEMALE SEXUAL HISTORY: ☐ experience pain during intercourse ☐ bleeding with intercourse ☐ high libido ☐ low libido ☐ headache after orgasm frequency of intercourse _________x/week/month PREGNANCY HISTORY: # of Pregnancies _____ DATE MISCARRIAGE ELECTIVE ECTOPIC ABORTION INFERTILITY C- SECTION TREATMENT FATHER? CONTRACEPTIVE USE: TYPE: FROM WHEN TO WHEN? IS CURRENT PARTNER THE REASON DISCONTINUED 6 acupuncture Essentials consultation form GYNECOLOGY/INFECTIONS: Notes: Office Use Only ☐ pelvic infection ☐ vaginal dryness ☐ gonorrhea ☐ ovarian cysts ☐ chlamydia ☐ colitis/enteritis ☐ syphilis ☐ toxoplasmosis ☐ endometriosis ☐ uterine fibroids/myomas ☐ mycoplasma ☐ cytomegalovisrus ☐ pelvic adhesions ☐ abnormal uterus shape ☐ ureaplasma ☐ tuberculosis ☐ cervicitis ☐ recurrent vaginitis ☐ genital warts ☐ trichomonas ☐ genital herpes ☐ abnormal pap smears ☐ cryo (freezing) or surgery of the cervix ☐ other problems: ______________________________________________________________________ Do you have, or have you ever experienced: ☐ hot flashes ☐ increased facial/body hair ☐ breast discharge ☐ vaginal discharge ☐ weight gain >10 pounds ☐ weight loss > 10 pounds Date of last pap smear _____/_____/_____ Date of last mammogram _____/_____/_____ MENSTRUAL HISTORY: Age of first period:_____ Are your periods regular? ☐ Yes ☐ No # days between periods: _____ Duration of periods (days): _____ Do you bleed between cycles? ☐ Yes ☐ No PMS SYMPTOMS: none before menstruation during menstruation at mid cycle emotional ☐ ☐ ☐ ☐ breast swelling ☐ ☐ ☐ ☐ breast tenderness ☐ ☐ ☐ ☐ back pain ☐ ☐ ☐ ☐ acne ☐ ☐ ☐ ☐ headaches ☐ ☐ ☐ ☐ bloating ☐ ☐ ☐ ☐ cramps ☐ ☐ ☐ ☐ ☐ Mild ☐ Moderate ☐ Severe 7 acupuncture Essentials consultation form Have you consulted a physician/dentist about the condition that you are currently seeking treatment? ☐ Yes EMERGENCY CONTACT NAME: _________________________________________________ ☐ No PHONE #: ___________________ ACUPUNCTURE ESSENTIALS CONSENT TO TREATMENT I do herby voluntarily consent to be treated with: acupuncture ☐ herbal therapy ☐, cupping ☐ tui na administered at Acupuncture Essentials, 7660 - 156 Street, Edmonton, AB. I understand that acupuncture is performed by the insertion of needles through the skin, and/or by the application of heat to the skin, at certain points on or near the surface of the body. Acupuncture attempts to restore normal physiological body functions, modify or prevent pain perception. I have been made aware that certain adverse side effects may result. These could include, but are not limited to, some local bruising, minor bleeding, fainting, temporary pain or discomfort, and possible temporary aggravation of symptoms. I understand that acupuncture has been safely practiced for centuries. I also understand that no guarantees concerning its use and effects are given to me and that I am free to discontinue treatment at any time. CANCELLATION POLICY: We need AT LEAST 24-hours notice for all appointment cancellations. Last minute cancellations will result in a service charge equal to 50% of the treatment cost. For all missed appointments, there will be a full service charge. I have carefully read and understand all of the foregoing and I am fully aware of what I am signing. _________________________________ Patient Name __________________________________ Patient Signature _________________________________ Parent’s/Guardian’s Name __________________________________ Parent’s/Guardian’s Signature 8 __________________________________ Date __________________________________ Date