Health History Intake Form (Page 2 of 2) in pdf

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:________________________________________

Health History Intake Form Page 2

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