Acupuncture Patient Intake/health History Form Page 2
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210815 Bathurst St.
Richmond Hill, ON L4C 9Y2
Tel.: 905-737-5559 Fax: 905-737-5556
Please check if you are experiencing or have experienced any conditions below:
Regional Areas of
Respiratory
Cardiovascular
Allergies
Concern
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Chronic cough
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High blood pressure
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Known allergies or
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Neck/ Head/
Hypersensitivities
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Bronchitis
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Low blood pressure
Face
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Shortness of breath
Chronic Congestive
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Shoulder
What?
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Asthma
Heart Failure
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Arm
□
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Emphysema
Heart Disease
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Chest/ Abdomen
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Anaphylaxis
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Other
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Myocardinal Infarction
Spine
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Skin
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Pelvis
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Phlebitis
irritations
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Hip
What?
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Cerebro-vascular
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Leg
accident (Stroke)
Medical Conditions
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Hands/ Feet
Infectious Diseases
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Presence of a pace
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Muscle weakness
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Diabetes
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Infectiuos skin conditions
maker or similar device
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Muscle soreness
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Cancer
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Tuberculosis
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Hemophilia
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Pins, plate,
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Skin conditions
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Hepatitis
implants
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General circulatory
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HIV
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Artificial joints
disorder
What?
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Cosmetic implants
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Other
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Varicose veins
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Joint problems
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Dizziness
(arthritis, etc)
What?
Reproductive
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Chest pain
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Osteoporosis
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Pregnancy
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Other
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Other
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Endometriosis
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Pelvic Inflammatory
Gastrointestinal
What?
What?
Disease
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Prolonged constipation
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Prostate condition
Irritable Bowl Syndrome
Neurological
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Chronic abdominal
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Epilepsy
Renal
Special Senses
discomfort
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Multiple Sclerosis
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Kidney stones
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Diarrhea
Vision Problems
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Loss of sensation
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Dialysis
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Vision loss
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Other
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Neuritis
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Nephritis
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Hearing loss
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Other
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Other
What?
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Altered taste
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Altered smell
What?
What?
CONSENT TO TREATMENT FOR ACUPUNCTURE THERAPY
I,
understand that acupuncture, and other modalities of Chinese Medicine (including
acupressure, massage, herbs, aromatherapy, cupping, and electrical stimulation), may cause minor discomfort, and may irritate the
.
skin or leave a mark or bruise
The therapists have provided me with information relevant to the treatment for the above listed complaints.
My therapist has thoroughly explained alternative treatment where applicable and relevant, as well as possible risks and side-effects
of my therapists’ proposed treatment plan.
The consequences of having treatments or not having treatments have been explained to me. I have been informed that I may
request the therapist to stop, modify or change the treatment plan.
I have read above and understand the consent to Acupuncture Therapy treatment.
Patient’s Signature
Date:
Therapist’s Signature
Date:
info@happyfamilywellness.ca
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