Acucare -Patient Consultation Formpage 1 of 4

AcuCare -Patient Consultation FormPage 1 of 4

Please complete and bring to your initial acupuncture session.

(INFORMATION CONFIDENTIAL – PLEASE PRINT) Date: ______

Name: ______Age: ______Sex: M / F ______

Address: ______Occupation: ______

City: ______Postal Code: ______Birth Date: ______Do you have Extended Health? __ yes __ no

Work Telephone: ______Home Phone: ______Mobile Phone: ______Email:______

Physician: ______Physician’s Diagnosis (if any): ______

Medications: ______

For what conditions: ______

Vitamins/Supplements: ______

Reason for visit: ______

What other treatments have you tried? ______

______

MEDICAL HISTORY (Check all that apply)

__ AIDS/HIV/Transmittable Disease__ Alcoholism

__ Allergies:to what? ______Bleeding disorders

__ Cancer__ Diabetes

__Heart Disease______Hepatitis A/B/C

__ Herpes__ History of family illness: ______

__ Multiple Sclerosis__ Pacemaker

__ Seizures__ Thyroid Disease

__ Tuberculosis__ High/Low blood pressure

__ Other: Injuries, Surgeries, Major Illnesses:______

Please provide details: ______

When? (dates): ______

Present Diet (Give example of day’s food and drink) :

Breakfast | Lunch | Dinner | Snacks

Food Cravings? ______

Food Intolerances? ______

AcuCare -Patient Consultation FormPage 2 of 4

How many glasses/cups do you drink each day of the following?

Water ______Soda ______Coffee ______Tea ______Alcohol ______Other Drinks ______

Do you perspire during the day? ______Do you perspire at night? ______

Are you always thirsty? ____ yes _____ no

Do you prefer: _____ hot or ______cold drinks?

Taste preferences (indicate 1-5; 1 = most liked; 5 = disliked)

Salty _____Sour _____ Bitter _____ Sweet ______Spicy _____

GASTROINTESTINAL

Do you or have you had? (check all that apply)

__ Belching__ Nausea __ Vomiting __ Ulcers __ Bloating __ Indigestion ___ Hernia __ Hemorrhoids

__ Acid Reflux

BOWEL MOVEMENTS

__ Irregularity__ Constipation__ Diarrhea __ Gas __ Burning

EXERCISE AND ENERGY

What kind of exercise do you engage in? ______how often? ______

How is your general energy level? ______

Do you or have you had? (check all that apply)

___ Panic Attacks___ Depression___ Anxiety___Nerves___ Fear___Poor Memory

___ Difficulty Concentrating

Do you have? (check all that apply)

___ Difficulty falling asleep___ Restless___ Disturbed sleepWaking up at _____ am / pm

URINATIONhow often? ______times per day color: ______

Do you have or have you had? (check all that apply)

Frequent urination ______Incontinence ______Burning ______Infections ______

GYNOCOLOGY

Are you still menstruating? ______Are you pregnant? ______

Irregular Menses _____Heavy flow _____Light flow _____Noflow _____ Blood clots ______

PMS _____Painful periods _____Uterine fibroids _____ Cystic breasts ______

Are you perimenopausal? ______Symptoms ______

Are you menopausal? ______Symptoms ______

AcuCare -Patient Consultation FormPage 3 of 4

RESPIRATORY, EAR/NOSE/THROATAND HEAD

Do you smoke? ___ no ____ yes ______times/day for ______years

Do you have or have you had? (check all that apply)

Frequent colds _____Asthma _____Dizziness _____ Cold sores _____ Bleeding gums ____ Dry mouth ____

Ear pain _____ Ringing in ears _____ Clogged/popping _____ Frequent headache _____

Migraine _____

CARDIOVASCULAR

Do you have or have you had? (check all that apply)

Palpitations ____Varicose veins ____ Spider veins ____Cold hands/feet ____ Mitral valve _____

Poor circulation ____ Irregular heart beat

SKIN AND HAIR

Do you have or have you had? (check all that apply)

Dry skin ____ skin rashes ____ Itching ____ Acne ____ Eczema ____

PERSONALITY TRAITS

Please list two positive personality traits (i.e. brave/risk taker, social, great listener)

1.

2.

Please list two negative personality traits (i.e. jealous, hard to accept others faults, hard trusting others)

1.

2.

Please list two challenges in life you are trying to overcome (i.e. trying to be more sensitive to others feelings, to learn to have patience, to not hold grudges)

1.

2.

AcuCare -Patient Consultation FormPage 4 of 4

Are there any additional health conditions that I should be informed of? ______

______

______

______

______

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I wish to opt-in to receiving the Acucare monthly educational newsletter? y/n ______

Note:

Cancellations will be allowed up to 24 hours before scheduled appointments only, otherwise a full treatment fee will still apply.

I, (PRINT NAME)______, have truthfully answered the above consultation. I am aware that acupuncture and cupping may in extreme cases cause bruising, slight bleeding at the site of needles, or in rare cases, a pneumothorax.

I accept this form as a signed consent to begin one or a series of acupuncture treatments, which may be supplemented by cupping, electrical stimulation, and ear acupuncture.

Signature: ______Date: ______