"Acupunture Patient Intake Form - Metrotown Acupuncture"

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Ladan Mohammadi, R.Ac, PhD.
202-6411 Nelson Avenue, Burnaby
www.metrotownacupuncture.com
Phone: 604-451-1737
Fax: 604-430-3911
Patient Intake Form
Patient Information
Last name:
First Name:
Middle Name:
Birth Name/Other Previous Names:
Gender: M / F
Home Address:
Date of Birth: (DD/MM/YY)
City:
Province:
Postal Code:
Age:
Phone:
Mobile:
Occupation:
Fax:
Email:
Family Contact Information
First name:
Last name:
Relationship to Patient:
Phone Number:
Mobile Number:
Emergency Contact information (If different from above)
First name:
Last Name:
Relationship to Patient
Phone Number:
Mobile Number:
Family Doctor Contact Information
Family Doctor Name:
Address:
How did you find out about us?
City:
Province:
Postal Code:
Phone:
Fax:
Email:
Reasons for Visit
1.
2.
3.
Past Medical History
Mumps
Herpes
Hepatitis
HIV+
Osteoporosis Tumor
Measles
High Cholesterol
Fracture
Arthritis
Gout
Diabetes 
Tuberculosis
High Blood Pressure
Muscle Sprain Stroke
Low Blood Pressure (Hypotension)
Cancer
Others:
Special Considerations
Organ Transplant
Pregnant Pacemaker
Implants
Others:
Allergies/Drug Reactions
Penicillin Peanut Dust Pollen Dairy Gluten Wheat Chocolate Caffeine
Others:
Ladan Mohammadi, R.Ac, PhD.
202-6411 Nelson Avenue, Burnaby
www.metrotownacupuncture.com
Phone: 604-451-1737
Fax: 604-430-3911
Patient Intake Form
Patient Information
Last name:
First Name:
Middle Name:
Birth Name/Other Previous Names:
Gender: M / F
Home Address:
Date of Birth: (DD/MM/YY)
City:
Province:
Postal Code:
Age:
Phone:
Mobile:
Occupation:
Fax:
Email:
Family Contact Information
First name:
Last name:
Relationship to Patient:
Phone Number:
Mobile Number:
Emergency Contact information (If different from above)
First name:
Last Name:
Relationship to Patient
Phone Number:
Mobile Number:
Family Doctor Contact Information
Family Doctor Name:
Address:
How did you find out about us?
City:
Province:
Postal Code:
Phone:
Fax:
Email:
Reasons for Visit
1.
2.
3.
Past Medical History
Mumps
Herpes
Hepatitis
HIV+
Osteoporosis Tumor
Measles
High Cholesterol
Fracture
Arthritis
Gout
Diabetes 
Tuberculosis
High Blood Pressure
Muscle Sprain Stroke
Low Blood Pressure (Hypotension)
Cancer
Others:
Special Considerations
Organ Transplant
Pregnant Pacemaker
Implants
Others:
Allergies/Drug Reactions
Penicillin Peanut Dust Pollen Dairy Gluten Wheat Chocolate Caffeine
Others:
Ladan Mohammadi, R.Ac, PhD.
202-6411 Nelson Avenue, Burnaby
www.metrotownacupuncture.com
Phone: 604-451-1737
Fax: 604-430-3911
Ongoing Health Conditions
Neck Pain
Memory Loss Carpal Tunnel
Headache
Asthma
Dizziness
Jaw Pain
Menses Issues Plantar Fasciitis
Fatigue
Depression
Arthritis
Bowel Problems
Slipped Disc
Stomach Pain Tingling in Legs and Arms
Allergies
Mid Back Pain
Hypertension Low Back Pain Poor Posture Knee or Hip Pain
Palpitations
Pinched Nerves in Back or Neck
Others:
Medical Conditions: Please indicate any hospitalizations, surgeries and injuries you have experienced:
rienced:
Hospitalization, Surgery, Injury
Date
Symptoms
Conditions Resolved?
Current medications/supplements: Please list ALL medications or supplements you take on a regular basis, and other
Medication/Supplement
Dose (if known)
Length of Use
Prescribing Practitioner
Are You Taking
Presently?
Family History: Has anyone in your family been diagnosed with any of the following conditions?

Alcoholism Alzeimer's Disease
Asthma
Cancer
Depression
Diabetes Drug Abuse
Heart Disease High Blood Cholesterol

Eczema
Osteoporosis Kidney DiseaseMental Illness
Epilepsy
Fibromyalgia
Multiple Sclerosis
Thyroid Disorder
Psoriasis
Osteoarthritis
High Blood Pressure
Others:
Ladan Mohammadi, R.Ac, PhD.
202-6411 Nelson Avenue, Burnaby
www.metrotownacupuncture.com
Phone: 604-451-1737
Fax: 604-430-3911
Patient Informed Consent to Treatment
I, understand the nature, risks and reasons for this procedure. I voluntarily consent to Acupuncture
including other traditional treatment methods (see point 1 below) and understand that I may withdraw
my consent and halt my participation at any time.
1.
I understand that Acupuncture includes the use of sterile, single-use needles to penetrate
the skin. Additional treatment methods can include, but are not limited to: Acupuncture,
Acupressure, the electrical stimulation of needles, Cupping, Moxibustion, Gua Sha,
Nutritional Advice, and Tuina. Before any of these procedures are performed, my
Acupuncturist will discuss my treatment options and only proceed if my consent is given.
2.
As with any procedure there are risks and symptoms of treatment which can include, but
are not limited to: slight pain, light-headedness or nausea, soreness, bruising, bleeding or
discolouration of the skin, and the possibility of other unforeseen risks. I freely accept the
risks involved with my procedure.
3.
I will inform my Acupuncturist if I currently have or develop any major health issues, if I
suffer from any type of major bleeding disorder, or if I use a pacemaker.
4.
I understand that I must let my Acupuncturist know if I am carrying, or believe to have any
infectious agents, including but at not limited to HIV, TB and Hepatitis. In some cases where
cross-infection is high, my practitioner may withhold treatment.
5.
I understand that there are no guarantees for the results of treatments and that
Acupuncture including other traditional treatment methods listed in point 1 above do not
often provide an instant cure. The length of my treatment depends on the severity of my
condition. In some cases my symptoms may temporarily worsen before they begin to
improve.
6.
I am responsible for the full and prompt payment after services have been rendered.
7.
I understand that I am expected to inform the clinic at least 24 hours prior to my
appointment if I need to cancel. Otherwise, I will be charged a $40 cancellation fee.
8.
I acknowledge that I have the right to ask any questions or refuse treatment. By signing this
form, I give my informed consent for Acupuncture and other traditional treatment methods
listed in point 1 above.
_____________________________
______________________________
Patient (or Legal Guardian) Signature
Date
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