Acupuncture Patient Intake/health History Form
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1
210815 Bathurst St.
Richmond Hill, ON L4C 9Y2
Tel.: 905-737-5559 Fax: 905-737-555
Acupuncture Patient Intake/Health History Form
An accurate health history is important to ensure that it is safe for you to receive an acupuncture treatment. All information gathered
for this treatment is confidential except as required or allowed by law. Written authorization will be required for release of any
information. This information may be shared amongst other health custodians or circle of care for purpose of your health care.
24 hour cancellation notice is required or a missed appointment fee will be charged.
Name:
Email:
Home:(
)
Work:(
_)
Cell:(
)
Address:
City:
Postal Code:
Date of birth:
/
/
Occupation:
First time for Acupuncture: YES / NO
D
M
Y
Family Physician:
Address:
If Doctor – Address:
Who can we thank for referring you here?
Reason for Acupuncture Treatment:
Indicate your problem by shading in the area
Medical Information
1.
Are you currently receiving any therapy from another health care practitioner?
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□
Medical Doctor
Massage Therapist
□
□
Chiropractor
Physiotherapist
□
□
Naturopath
Dietitian
Are you taking any medications? YES / NO. If “YES”, what?
2.
Are you pregnant? YES / NO. If “YES”, what trimester?
3.
4.
Lifestyle Choices / Habits (please check all that applies to you):
□
□
□
□
□
Exercise
Alcohol/Drugs
Coffeine
Smoking
Other
Surgeries YES / NO (if “YES”, please indicate nature and date of procedure) _____________________________________
5.
________________________________________________________________________________________________________
Accidents YES / NO (if “YES”, please indicate the date of accident) _____________________________________________
6.
□
□
□
7.
Current Level of Stress
Low
Moderate
High
8.
General Health Status:
□
□
□
□
Excellent
Good
Fair
Poor
info@happyfamilywellness.ca
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