Patient Intake Form (Page 3 of 3) in pdf

Gynecological / Reproductive

 Ovarian Cysts

 Vaginal discharge

 PMS

 Irregular menstruation

 Painful menstruation

 Endometriosis

 Uterine / Ovarian Fibroids

 Fibrocystic breast tissue

 Abortions(When):

 Pregnancies(How

 Caesarean births(How many):

 Infertility

many):

Birth control?  Yes  No:

Since when?____________

Type:____________

Psychological / Neurological

 Seizures

 Bad Temper/Irritability

 Areas of numbness

 Vivid dreams

 Lack of coordination

 ADD/ADHD

 Easily susceptible to stress

 Waking up at night:

 Anxiety/Panic Attacks

 Vertigo/Dizziness

 Seasonal Affective Disorder

 Depression

 Nervousness

 Concussion

 Poor Sleep

 Bi-Polar Disorder

 Yes  No

Have you ever been treated for emotional problems?

 Yes  No

Have you ever considered or attempted suicide?

 Yes  No

Have you ever been treated for substance abuse?

Comments: Please inform us of any other problems you would like to discuss:

I hereby declare that the information that I have given above regarding my health condition is accurate and true to

the best of my knowledge.

Signature of Patient:_________________ Date:_______________

Patient Informed Consent to Treatment

I voluntarily consent to Traditional Chinese Medicine/Acupuncture and understand that I may withdraw my consent and halt my

participation at any time.

I understand that some of the techniques used under the scope of Traditional Chinese Medicine include 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 or Moxibustion, Gua sha, and Structural Techniques. Before any of

these procedures are performed, my practitioner will discuss my treatment options and only proceed if my consent is given.

My practitioner has informed me of the risks and symptoms of treatments, 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.

I will inform my practitioner 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.

I understand that I must let my practitioner 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.

I understand that there are no guarantees for the results of my treatments. Traditional Chinese Medicine does 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.

I am responsible for the full and prompt payment after services have been rendered.

I have discussed the content of this form with my practitioner. I acknowledge that I have asked any questions I may have

and received answers I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine

treatments.

Patient Name:

Signature:

Date:

Page 3 of 3

Patient Intake Form Page 3

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