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5615- 4th Street NW Calgary AB

403-282-1166

PATIENT INTAKE FORM

Full name______Date: ______

Sex F  M

Date of birth(Y/M/D)______Age______

Occupation______

E-mail address ______

Home phone ______Work phone______Cell phone______

Address:______

In emergency notify______

Marital status SingleMarried # of children______

Family physician______Chiropractor______

Have you been treated by acupuncture before? Yes No

How did you find out about this clinic? Friend/Relative ______

Periodicals Location/Walk by Website Referred by______

Yellow pagesOther (please specify): ______

Main Problem(s): You would like us to help you with ______

When did the problem begin?______What are the precipitating factors?______

Have you been given a diagnosis for this problem? If so, what?______

To what extent does this problem interfere with your daily activities (work, sleep, sex, etc.)?

What kind of treatment(s) have you tried?______

What makes this problem worse? ______What make this problem better?______

Is there anybody in your family with the same similar problems?

Remarks/additional information:______

Medical History: (please include the month/year when the diagnosis was established)

Please indicate a ‘P’ or ‘C’ if the following apply. P=Past C=Current

Medication Medication

______Fibromyalgia Yes No ______Hepatitis Yes No

______Thyroid Disease Yes No______Seizures Yes No

______HIV/AIDS positive Yes No ______Venereal Disease Yes No

______Digestive disorders Yes No ______Tuberculosis Yes No

______Breathing problems Yes No ______Heart Disease or Stroke Yes No

______High Blood Pressure Yes No______High Triglycerides Yes No

______Cancer Yes No______Lung/Pulmonary DiseaseYes No

______Kidney Disease Yes No _____Osteoporosis Yes No

______Ulcer Yes No ______DiabetesYes No

______Arthritis Yes No ______Anemia Yes No

______Neuromuscular Disease Yes No ______Gallbladder Disease Yes No

______Psychological Challenges Yes No

Other (please specify):

Surgeries:______Hospitalization:______Significant trauma:______

Allergies (drugs, chemicals, foods, animals): ______

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5615- 4th Street NW Calgary AB

403-282-1166

Family Medical History: (please specify family member)

______Cancer ______Diabetes ______Hepatitis ______Autoimmune disease:

______Hypertension ______Heart disease ______Stroke______Asthma

______Alcoholism ______Miscarriage ______Other (please specify)

Medication:

Please list any medications you have taken within the last two (2) months. Include vitamins, OTC drugs,

herbs, etc. and dosages).

Occupation:

Do you usually work : indoors  outdoors?

Occupational stressors (chemical, physical, psychological, etc.):______

Personal:

Height: ______Weight (present): ______Weight (1 year ago): ______

Weight (maximum): ______at year ______

Habits:

Do you smoke? ______What? ______How much per day? ______Since when? ______

Please describe any use of drugs for non-medical purposes:

Do you exercise regularly? Yes No

Please describe exercise program: ______

How many hours do you sleep in general? ______When do you usually go to bed? ______

Nutrition:

Do you drink caffeinated beverages? Yes No If so, how many per day? ______

Do you drink alcoholic beverages? Yes No If so, how many per week? ______

How much water do you drink per day? ______Do you prefer Warm  Cold

Are you a vegetarian?Yes Yes, but not strict  No

Do you eat a lot of spicy food? Yes No

Do you prefer Sweet  Spicy  Sour Salty

Please describe your average daily diet (please be as specific as possible)

Morning______

Afternoon______

Evening______

Snacks______

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5615- 4th Street NW Calgary AB 403-282-1166

Head

HeadachesEyesThroat

MigrainesBlurred vision Sore throat

Memory LossPain Difficulty swallowing

ConcussionsDryness Enlarged thyroid

DizzinessRednessDry Throat

Other ______Glasses/lenses Other ______

Eyestrain

EarsColor blindness Respiration

Poor hearingNight blindness  Asthma

 RingingCataracts Bronchitis

Frequent ear infectionsSpots in front of eyesChest pain

 Excess Discharge Decreased VisionCough

Other ______Other ______Coughing blood

Difficulty breathing

NoseMouthPhlegm

Frequent colds Gum problemsPneumonia

Sinus trouble Teeth problems Wheezing

Allergies Tongue/lip sores  History of smoking

Nosebleeds Jaw clicking/pain Coughing blood

Drainage Unusual taste Other ______

Other ______Skin

Heart and ThoraxCirculationChange in hair/skin texture

Palpitations Bruise easilyDryness

Rapid heart beat  Cold hands and feet Dandruff

High blood pressure FaintingEczema

 Low blood pressure PhlebitisHair loss

 Tightness in chest Varicose veins Hives

ArteriosclerosisAnemiaItching

 Prior heart attack  Other ______Night sweats

Gastrointestinal Pimples

Colitis or IBSExcessive Sweating

 Stomach painUrogenitalRashes

Poor appetiteFrequent urination Recent moles

Bad breath Difficulty urinatingOther ______

Excessive hunger Frequent UTIs

Excessive thirst Waking to urinate

Belching or heartburn Retention of urine/scanty urine

GasDribbling of urineSleep

Abdominal pain/cramps Bed wetting Insomnia

Parasites Pause of flow - urination Drowsiness

Nausea Itching of genitals Night sweats

Constipation Burning urinationSleepwalking

Chronic laxative use Other ______Excessive dreaming

Loose stools or diarrhea Not enough

Blood in stools  Easily Awoken

Black stoolsOther ______

Hemorrhoids

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5615- 4th Street NW Calgary AB 403-282-1166

Neuromuscular/skeletalWomen’s issuesEnergy level

Stiff neck Painful menstrual periods Low energy

Low back soreness/weakness Cramps or backache Excessive energy

Shoulder trouble Fertility problems Hard to wake up

Spinal curvature Ovarian cysts Energy drop in afternoon

Pain between shouldersExcessive flow Sudden energy drops

Knee trouble Endometriosis

Swollen joints Light flow Emotional

Painful joints  Clotting Depression

Hip pain Irregular cycle Mania/bipolar

Arthritis Hot flashes Anxiety

Hand/wrist pain Vaginal discharge Bad temper

Knee pain Fibrocystic breasts Mood swings

Sprain Breast tenderness Stressed

Hernia PMS  Sadness/ Grief

Sciatica Abnormal bleeding  Fear

Numbness or tingling Low sex drive Relationship issues

Paralysis Other ______ Other______

Other ______Number of pregnancies ______

Number of births ______

Mens issuesNumber of miscarriages ______

Prostate problemsNumber of abortions ______

DischargePremature births ______

ImpotenceCesarean sections ______

Frequent seminal emissionsAge of first menses ______

Fertility problemsDuration of periods ______

Ejaculatory problemsCycle length ______

Painful/swollen testiclesDo you practice birth control?

Other ______NoYes; type: ______

FrontBack

Please circle painful or

Distressed areas here.

Signature:______

Informed Consent for Acupuncture Treatment

I ______hereby agree and consent to the performance of acupuncture and other Oriental Medicine procedures. I understand that such procedures may include, but are not limited to acupuncture, moxibustion, cupping & gua-sha (dermal friction technique), infrared heat lamp, Chinese or western herbal medicine, and nutritional counseling based on traditional Chinese medical theory.

Acupuncture is a technique utilizing fine stainless steel needles inserted at specific points in the body to correct various ailments.

Moxibustion is the application of indirect heat by burning a stick of compressed Folium

Artemisiae vulgaris, commonly known as Mugwort, over acupuncture points.

Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Bruising is a common side effect of cupping, and the bruising can last up to a week.

I have been informed that in all acupuncture treatments only sterile, disposable needles are used according to the Clean Needle Technique protocol, to ensure the safest acupuncture treatment possible.

I have been informed that acupuncture is a safe method of treatment, but may have some side effects, including bruising, numbness or tingling, dizziness or fainting, minor swelling, bleeding, hematoma may occur at the site of insertion and may last a few days. A sensation of lightheadedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if

I experience any symptoms or problems. I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed.

I am relying on the TCM practitioner to exercise judgment during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Oriental Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment,

I may request the practitioner to stop, modify or change the treatment plan.

I state that I do not have the following conditions: pregnancy, bleeding disorders, pacemaker, local infections; or am currently taking anticoagulants. If I have any of the above conditions, I have listed them here: ______

______

By voluntarily signing below I, ______, hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions and that I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition and for any future condition(s) for which I seek treatment.

______

Print Name of Patient Signature of Patient Date