Acupuncture Health History Form Personal Information Name: ________________________

Date of Birth: _____________________

Phone: ________________________

Height: ________

Email: _________________________

Sex: M / F

Address: _______________________

Occupation: ______________________

Weight: ________

______________________________ How did you hear about us? _____________________________________________ Would you like to receive updates about our clinic via email?

Yes

No

Contacts Physician(s) Information: Name: ____________________ Phone: ____________________

Emergency Contact: Name: ____________________ Relation: __________________ Phone: ____________________

Name: ____________________ Phone: ____________________

Lifestyle Choices Habits (please check all that apply, and provide the frequency and amount of use): □ Alcohol ____________________ □ Tobacco ____________________ □ Caffeine ____________________ □ Sugar ____________________ □ Drugs ____________________ □ Other ____________________ Diet (without going into great detail, please describe your daily diet, indicating which foods you consume most often): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Exercise (please indicate your frequency of exercise): □ daily □ 3-4 times weekly □ 1-2 times weekly

□

not at all

Please describe your typical routine and/or list your favorite activities: ______________________________________________________________________ ______________________________________________________________________

Medical Information Health Concerns (please briefly describe the reason for today’s visit): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Health Conditions (please check all that apply, past and present): □ AIDS □ German Measles □ Multiple Sclerosis □ Alcoholism □ Goiter □ Mumps □ Allergies □ Gout □ Obsessive □ Anemia □ Heart Disease □ Compulsive Disorder □ Anorexia □ Hepatitis A □ Osteoarthritis □ Appendicitis □ Hepatitis B □ Osteomalacia □ Arteriosclerosis □ Hepatitis C □ Osteoporosis □ Asthma □ Hernia □ Parkinson’s Disease □ Bleeding Disorder □ Herpes Simplex 1 □ Pneumonia □ Bronchitis □ Herpes Simplex 2 □ Polio □ Bulimia □ High/Low Blood Pressure □ Prostate Disorders □ Cancer □ High Cholesterol □ Psychiatric care □ Candidiasis □ Hyperglycemia □ Rheumatoid Fever □ Cataracts □ Hypoglycemia □ Rheumatoid Arthritis □ Chicken Pox □ Jaundice □ Stomach Ulcers □ Chronic Fatigue □ Kidney Disorders □ Stroke □ Chronic Pain □ Liver Disorders □ Thyroid Disorders □ Convulsions / Seizures □ Low Blood Pressure □ Tonsillitis □ Depression / Anxiety □ Lupus □ Tuberculosis □ Diabetes □ Measles □ Urinary Tract Infections □ Eczema / Psoriasis □ Menstrual Disorders □ Venereal Disease □ Emphysema □ Migraines □ Other ______________ □ Epilepsy □ Miscarriages □ Gallbladder problems □ Mononucleosis Family History: □ Arthritis □ Asthma □ Cancer □ Depression □ Diabetes

□ Drug Dependencies □ Heart Disease □ High Blood Pressure □ Kidney Disease □ Liver Disease

□ Obesity □ Stroke □ Other _______________ □ Other _______________

Allergies (Please list any allergies): ______________________________________________________________________ ______________________________________________________________________ Hospitalizations (Please note circumstances): ______________________________________________________________________ ______________________________________________________________________ Medications and Supplements: Medication and/or Type Dosage ___________________ ______ ___________________ ______ ___________________ ______

Medication and/or Type ___________________ ___________________ ___________________

Dosage _______ _______ _______

Symptoms (Please check all that apply within the past three months): General □ Insomnia □ Dream-disturbed sleep □ Excessive sleep □ Weight gain □ Weight loss □ Fatigue □ Dizziness □ Numbness □ Frequent chills □ Fever □ Premature hair loss □ Premature greying Respiratory □ Cough □ Excessive phlegm □ Cough with phlegm □ Cough with blood □ Asthma □ Shortness of breath □ Common Cold Circulatory □ Cold hands and feet □ Excessive bleeding □ Easy bruising □ Discoloration Cardiovascular/ Chest □ Right-sided rib pain □ Chest pains/ tightness □ Palpitations □ Irregular heartbeat □ Rapid heart rate □ Blood clotting disorder Digestive/ Excretory □ Nausea □ Vomiting □ Diarrhea □ Loose stools □ Constipation □ Hemorrhoids □ Rectal pain □ Excessive hunger □ Loss of appetite □ Food allergies/sensitivities □ Abdominal bloating/gas □ Belching □ Acid Reflux □ Hiccups □ Stomach pain □ Abdominal pain

Nervous System □ Tremors □ Poor balance □ Seizures □ Change in motor control □ Change in sensation Musculoskeletal □ Muscle cramps □ Joint Pain □ Swollen joints □ Paralysis □ Neck / shoulder tension □ Body aches □ Hand and arm pain □ Hip and leg pain □ Foot and ankle pain □ Low back pain □ Upper back pain Mental / Emotional □ Depression □ Nervous tics □ Anger □ Irritability □ Easily stressed □ Fear □ Grief □ Anxiety □ Forgetfulness □ Cloudy-thinking □ Obsessive behavior □ Lack of motivation □ Abuse survivor Head and Face □ Migraines / headaches □ Jaw pain / TMJD □ Facial tics □ Facial paralysis Eyes □ Degenerating vision □ Blurry vision □ Night blindness □ Red eyes □ Eye pain □ Visual spots

Nose □ Sinusitis □ Post-nasal drip □ Nasal polyps □ Nose bleeds

Mouth and Throat □ Sore throat □ Hoarse voice □ Difficulty swallowing □ Mouth ulcers □ Dry mouth/throat □ Excessive thirst □ Lack of thirst □ Teeth pain □ Gum problems Ears □ Ringing in the ears □ Poor hearing □ Earaches □ Ear infection Skin □ Eczema □ Psoriasis □ Hives □ Acne □ Fungal infections □ Itchy skin □ Shingles □ Dry skin □ Change in color/texture □ Dandruff □ Excessive sweating □ No sweating Urinary / Genital □ Urinary tract infections □ Kidney stones □ Urinary incontinence □ Frequent urination □ STIs □ Painful urination □ Dribbling urination □ Foamy urine □ Bloody urine □ Genital pain □ Genital itching Men’s Health □ Impotence □ Infertility □ Seminal emissions □ Premature ejaculation □ Altered libido □ BPH □ Other:

_________________

Women’s Health □ Painful intercourse □ Infertility

□ Endometriosis □ Vaginal dryness

□ Altered libido □ Other _____________

Menstruation: How many days between periods? _____ Please indicate if you experience any of the following between periods: □ Vaginal discharge □ Bleeding □ Cramps/ Pain How many days in duration are your periods? _____ Please indicate the quality of blood: □ Light red □ Bright red □ Other _____________ □ Dark red □ Clotted □ Other _____________ Please indicate the quantity of blood: □ Heavy flow □ Normal flow □ Light flow If you experience any cramping, please indicate when: □ Before menstruation □ During menstruation □ After menstruation Do you experience breast tenderness? Y/N When? _________________________ Pregnancy: How many pregnancies have you had? ________ Have you had any miscarriages? Y/N Indicate any pregnancy-related difficulties: ___________________________________ _____________________________________________________________________ Are you currently pregnant? Y/N Are you trying to become pregnant? Y/N Are you currently using contraceptive(s)? Y / N If yes, what type and for how long: _________________________________________ Menopause: Please indicate your current status: □ Premenopausal □ Perimenopausal

□ Postmenopausal

If applicable, at what age did menopause begin? ______ Please indicate any menopause-related symptoms: □ Hot flashes □ Vaginal dryness □ Night sweats □ Insomnia

□ Mood swings □ Depression

________________________________________________________________

Patient acknowledgement and consent Cancellation policy: 24 hours notice required! Full payment may be required for late cancellations or missed appointments, fee payable before next treatment. Fee Policy: I understand and agree that the cost of treatment is my responsibility, should private insurers, MSP, ICBC, DVA, WCB or other providers fail to reimburse the clinic for services provided. All outstanding accounts over 60 days are overdue and will be charged interest at the rate of 24% per annum. Privacy Statement: With my signature below I authorize the collection, use, and disclosure of personal information, as defined in the Personal Information and Privacy Act (PIPA) and as is required for treatment and related administrative purpose. I understand that all my personal information is confidential and must be treated in accordance with PIPA.

I, __________________________________________________ (please print), hereby request and consent to the performance of Acupuncture and other procedure related to Acupuncture including the use of herbs, cupping, and/or acupressure. I understand and I am informed that there are possible side effects from the practice of Acupuncture including, but not limited to: minor bleeding or bruising, minor pain or soreness, nausea, fainting, infection and possible stuck or bent needles. If cupping is used during treatment, I understand that bruising is inevitable. I understand that only pre-sterilized needles will be used and that all acupuncture needles are properly disposed of after each and every treatment. By signing this I acknowledge that I have had the opportunity to ask questions about the above content, and that I agree to the above-mentioned treatment techniques.

Signature: _____________________________

Date: _______________________