Rehab and Wellbeing Centre at Mt.Sinai
Mt.SinaiHospital
600 University Ave., Room 1175
Toronto, Ontario M5G 1X5
Tel: (416) 619-5546 Fax: (416) 619-5548
Acupuncture Questionnaire
Please take a few moments to fill out this questionnaire carefully. All answers will be held strictly confidential. If you have any questions, please ask us. Please fill in this page only. Thank you.
First Name:______Last Name:______Sex: M / F Age:______
Address:______City:______Postal Code:______
Home Phone: ( )______Work Phone: ( )______
Date of Birth: MM / DD / YY Place of Birth:______Years in Canada:______
Living Arrangement: Married Single OtherOccupation:______
Family Physician:______Phone No.: ( )______
Address:______City:______Postal Code:______
How did you find us? Referred by:______Media Ad Street signs Other
What is your major health concern?______
Have you tried Acupuncture before?______
Email Address: ______
Medical History (please include dates and indicate if familial)
Date: ______
Rehab and Wellbeing Centre at Mt.Sinai
Mt.SinaiHospital
600 University Ave., Room 1175
Toronto, Ontario M5G 1X5
Tel: (416) 619-5546 Fax: (416) 619-5548
Acupuncture Questionnaire
Hospitalizations
Pregnancy
Allergies
Dermatitis
Prolonged Bleeding
Heart Disease
High / Low Blood Pressure
Lung Disease
Liver Disease
Kidney Disease
Diabetes
Cancer
Hepatitis
AIDS
Thyroid Disease
Venereal Disease
Migraines
Seizure
Date: ______
Rehab and Wellbeing Centre at Mt.Sinai
Mt.SinaiHospital
600 University Ave., Room 1175
Toronto, Ontario M5G 1X5
Tel: (416) 619-5546 Fax: (416) 619-5548
Acupuncture Questionnaire
Please write down details for any items checked above or other significant illnesses/trauma:
______
______
______
Please list all medications you are taking (include length of use):
Prescription:______
Non-prescriptive (eg. aspirin, antacids, vitamins, herbs):______
______
Family Medical History (please indicate relationship)
Date: ______
Rehab and Wellbeing Centre at Mt.Sinai
Mt.SinaiHospital
600 University Ave., Room 1175
Toronto, Ontario M5G 1X5
Tel: (416) 619-5546 Fax: (416) 619-5548
Acupuncture Questionnaire
Allergies
Diabetes
Asthma
Cancer
Heart Disease
High Blood Pressure
Seizures
Stroke
Other:
Date: ______
Rehab and Wellbeing Centre at Mt.Sinai
Mt.SinaiHospital
600 University Ave., Room 1175
Toronto, Ontario M5G 1X5
Tel: (416) 619-5546 Fax: (416) 619-5548
Acupuncture Questionnaire
Please list any other problems you would like to discuss:
In case of emergency notify:______Phone #:______
Chiropractic, Massage, Physiotherapy, and Acupuncture care may be covered by extended health care plans. These appointments are NOT covered by OHIP. Please check with your extended health care plan administrator to see if your treatment is covered.
You are required to pay for each treatment at the time of your visit. Payment may be made by cash, debit, Visa, or Mastercard. Fees are subject to change without notice.
If you are going to be late for your appointment please contact us as soon as possible. We require 24 hours notification for cancelled or rescheduled appointments. A late cancellation or no show will be charged for the full fee of the appointment.
All information obtained for treatment or diagnosis is confidential except as required or allowed by law or except to facilitate diagnosis/assessment or treatment. You will be asked to provide written authorization for release of any information.
Patient’s Statement of Agreement:
I verify that I have read and understood the above and agree to follow the terms and conditions outlined.
Signed: Date:
Patient’s Name (please print):
Date: ______