Acupuncture Naturally

Dr. Brenda Kohut, Registered Acupuncturist,

Certified Shiatsu Therapist

Name: ______Date: ______

Address: ______Occupation: ______

Home Phone: ______Other Phone: ______

Email: ______Date of Birth: ______

Emergency Contact: ______

Shiatsu is practiced through clothing by applyingpressure and comfortable stretches. Shiatsu leverages the principles of acupuncture, however no needle is used.

Usually treatments are on the whole body. Different parts of the body can be treated, in order to release tensions and promote free flow of Chi energy.

Health History

Current reason for seeking Shiatsu Therapy:

Is there any area of your body that you do not want touched? Yes No

If yes, please specify:

Please indicate if any of the following applies to your situation:

Y N Bruise easily Y N Infectious disease (incl. flu)

Y N Brittle bones or osteoporosis Y N Diabetes

Y N High, or low blood pressure Y N Cancer

Is there anything that the therapist might not be able to see or that might be hidden by your clothing: e.g. open wound, recent scar, broken skin or skin issue, varicose vein, nodule, tumor, etc… Y N

For women: Is there any chance that you may be pregnant? Y N

Past or present medical or psychological problems

Head (ears, eyes, hair, nose, throat)

Chest/trunk/abdomen

Gynecological

Muscle/skeletal

Allergies—respiratory, food, chemicals, drugs

Surgeries

Significant trauma (auto accidents, sports injuries, etc.)

Significant illnesses that you or family members have or have had

Self / Family / Self / Family
alcoholism / heart disease
anemia / hepatitis
arthritis / HIV/AIDS
asthma / hypertension
cancer / miscarriage
chronic fatigue / thyroid disease
diabetes / stroke
digestive disorders / Depression/anxiety

Lifestyle

When do you usually go to sleep? ______When do you usually get up? ______

How much fluid do you drink daily? water ______coffee ______

tea, ______carbonated beverages ______juice ______

How much and/or how often do you drink alcohol? ______

How often do you have a bowel movement? ______Formed/loose? ______

Are you a vegetarian? Yes NoDo you eat spicy food often? Yes No

What do you typically eat:

Breakfast:

Lunch:

Dinner:

Do you smoke? Yes NoIf so, what and how much per day? ______

Do you use any recreational drugs? If so, what and how often? ______

Medications during past two months (include vitamins, drugs, birth control pills, herbs)

Do you exercise? If so, what kind and how often?

What do you for fun? What are your hobbies?

Please circle areas of concern

Shiatsu Therapy Consent

I have had the opportunity to ask questions about this confidential form and about Shiatsu therapy, and I understand the nature of Shiatsu therapy.

I understand that my record or any information within my record is confidential.

I understand that open communication with the therapist is welcome and appreciated, and that I may change or stop the course of treatment at any time. By my consenting to treatment, I will not hold the Shiatsu therapist personally liable for any ill effect or injury, incurred before, during, or after the course of the treatment. I also releaseBeverly Chiropractic & Wellness (its owners, employees and contractors) from any claims, demands and causes of action arising from my voluntary participations in the Centre’s Shiatsu services.

I understand that Shiatsu Therapy may include other modalities such as cupping, gua sha, herbology, auricular therapy.

I have been informed about the charges that apply.

This consent is signed before the first treatment begins. It applies to the entire course of treatment for my condition and for future conditions for which I seek treatment.

Name(printed): ______Signature: ______

Today’s Date : ______

Therapist’s Signature: ______