"Health History Intake Form - Atlas"

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ACUPUNCTURE
Health History Intake Form
Name: ________________________________________
Phone: (H) ________________________________
(W) ________________________________
DOB: _________________________________________
(C) ________________________________
Email: ________________________________________
Address: _______________________________________
City: _________________
Prov: _________
Postal Code: ____________________________________
Family Doctor: _____________________________
Occupation: ____________________________________
Employer: _________________________________
MSP CareCard#: ________________________________
How did you hear about us? _______________________________________________________________________
**Ask about our referral program to save on your next visit.
What is your primary reason for seeking treatment. Note dates, previous treatment and results if relevant.
___________________________________________________________________________________________________________
Previous illness: ______________________________________________________________________________________________
Surgeries: ___________________________________________________________________________________________________
Traumas (accidents, falls, scars, emotional traumas inc.): ____________________________________________________________
Allergies (food, drugs, etc.): ____________________________________________________________________________________
Current medications or supplements (drugs, vitamins, herbs, etc.): _____________________________________________________
Describe any work or home related stress: _________________________________________________________________________
Describe frequency and type of exercise: __________________________________________________________________________
Do you consume or use:
Caffeine
Alcohol
Recreational Drugs
Soda
Cigarettes
Does anyone in your immediate family have or have had any of the following:
Kidney Disease
TB
Thyroid Problems
Cancer
Ulcers
Heart Disease
Asthma
High Blood Pressure
Mental/Emotional Disorders
What emotions do you most commonly fee?
Fear
Worry
Joy
Anger
Calm
Sadness
Indecision
Other:_________________________________
For women only:
Age menstruation began:______________ ended: ______________ length of cycle: _______________
Painful
PMS
Clotting
Are you taking HRT or BCP?
Are you pregnant? ______________ How many months?______________
ACUPUNCTURE
Health History Intake Form
Name: ________________________________________
Phone: (H) ________________________________
(W) ________________________________
DOB: _________________________________________
(C) ________________________________
Email: ________________________________________
Address: _______________________________________
City: _________________
Prov: _________
Postal Code: ____________________________________
Family Doctor: _____________________________
Occupation: ____________________________________
Employer: _________________________________
MSP CareCard#: ________________________________
How did you hear about us? _______________________________________________________________________
**Ask about our referral program to save on your next visit.
What is your primary reason for seeking treatment. Note dates, previous treatment and results if relevant.
___________________________________________________________________________________________________________
Previous illness: ______________________________________________________________________________________________
Surgeries: ___________________________________________________________________________________________________
Traumas (accidents, falls, scars, emotional traumas inc.): ____________________________________________________________
Allergies (food, drugs, etc.): ____________________________________________________________________________________
Current medications or supplements (drugs, vitamins, herbs, etc.): _____________________________________________________
Describe any work or home related stress: _________________________________________________________________________
Describe frequency and type of exercise: __________________________________________________________________________
Do you consume or use:
Caffeine
Alcohol
Recreational Drugs
Soda
Cigarettes
Does anyone in your immediate family have or have had any of the following:
Kidney Disease
TB
Thyroid Problems
Cancer
Ulcers
Heart Disease
Asthma
High Blood Pressure
Mental/Emotional Disorders
What emotions do you most commonly fee?
Fear
Worry
Joy
Anger
Calm
Sadness
Indecision
Other:_________________________________
For women only:
Age menstruation began:______________ ended: ______________ length of cycle: _______________
Painful
PMS
Clotting
Are you taking HRT or BCP?
Are you pregnant? ______________ How many months?______________
From the following list of symptoms write:
1-for those you experience occasionally or mildly
2-for frequent or moderately severe
3-for disabling or persistent
Fatigue
Difficulty waking up
Change in libido
Recent weight gain or loss
Loss of appetite
Hot hands & feet
Burning or urgent urination
Genital problems
Indigestion
Cold hands & feet
Frequent urination
Numbness or tingling
Stomach ache
Aversion to hot or cold
Nocturnal urination
Soft or brittle nails
Abdominal bloating
Easy bruising
Incontinence
Dry skin
Binge eating
Chronic sore throat
(stress induced)
Acne
Nausea
Nosebleeds
Low back pain
Eczema
Vomiting
Lymphatic swelling
Upper back pain
Psoriasis
Acid regurgitation
Palpitations
Broken bones
Itchy skin
Loose stool
High blood pressure
Water retention
Fungal infections
Diarrhea
Low blood pressure
Headaches
Cough
Constipation
Chest discomfort
Migraines
Wheezing
Flatulence
Tightness in chest
Concussions
Shortness of breath
Bad Breath
Poor memory
Blurry Vision
Decreased sense of smell
Sores in mouth or on tongue
Difficult concentrating
Sore dry eyes
Post nasal drip
Fevers
Irritable/jittery
Eye infections
Nasal congestion or
Sweating without exertion
Ringing in Ears
Floaters
discharge
Night sweats
(high pitch
low pitch)
Cataracts
Feeling of ‘spaciness’
Hot, painful joints
Hearing loss
Glaucoma
Bitter taste in mouth
Skin eruptions or rashes
Loose teeth
Neck & shoulder tension
Hemorrhoids
Thirst
Gum disease
Muscle craps
Seizures
Difficulty falling asleep
Hair loss
Muscular weakness or spasm
Tics
Difficult staying asleep
Dizziness
Lack of strength
Depression
Dream disturbed sleep
Anxiety
Loss of balance
Sensation of heaviness
Informed consent:
I, _______________________________________________ understand that:
Acupuncture and other aspects of traditional Chinese medicine (including but not exclusive to acupressure, body-work, facials, moxibustion,
cupping and electrical stimulation) may cause minor discomfort and may irritate the skin or leave a mark, bruise or burn. Other possible ef-
fects may include sensation of light headedness and post treatment fatigue. I also understand that in some instances symptoms may temporar-
ily worsen before improving. This is referred to as ‘healing crisis’ and is most often normal. I recognize that if my condition worsens, I should
get in touch with the treating acupuncturist or seek other appropriate medical attention.
Existing & Potential Health Conditions:
During my initial visit, I have informed the acupuncturist of any of the following conditions:
Chronically impaired or hyper functioning immune system
Bleeding conditions
Low or High Blood Pressure
HIV, hepatitis or any other communicable diseases
Existing cardiac pacemaker
Extreme fatigue
History of seizures
Or any other condition which, with knowledge of myself, suspect may affect my treatment. I also agree to notify the treating acupuncturist in the
vent that any of these conditions develop in my health as they will have bearing on the effects of any subsequent treatment.
Cancellation:
I agree to give 24-hours notice to change or cancel my appointment. Otherwise, I will expect to be charged the full treatment fee.
Responsibility:
I agree to attend my scheduled appointment on time and to abstain from the use of drugs or alcohol prior to treatment. I understand and
realize that no claims, promises or guarantees are being made. I accept both the risk and effectiveness of all treatment.
Privacy Statement
I authorize the collection and use of personal information as is required for therapeutic treatment and related administrative purpose. I
understand that all of my personal information is confidential and will not be released without my signed consent.
I certify that the forgoing information supplied to me is true and complete to the best of my knowledge. I understand that I am required to
disclose my involvement in any WCB, ICBC, or other medical-legal disputes. I understand I retain the right to refuse or stop any treatment
that is being given at any time. I understand the practitioner retains the right to refuse treatment of any client if the provisions of such
treatment pose risk or harm to either the client or the practitioner. I understand that if under the age of 18 I must have a parent and/or
guardian sign consent to have any massage therapy treatment. I consent to treatment.
Signature: ___________________________________
Parent/Guardian Signature: _______________________________________
Date:________________________________________
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