Acupuncture Intake

ACUPUNCTURE/TCM - Patient Intake Form

An accurate health history ensures that it is safe for you to receive an acupuncture treatment, and helps the acupuncturist determine a proper treatment plan. Should your health status change in the future, please let us know.
All information gathered on this form is confidential. Your written authorization is legally required before any of this information can be released.

Personal Information

How did you hear about us?

Name (first/last)
Cell#
Cell Provider
Address
City
Postal Code
Sex
Birth Date (mm/dd/yyyy)
Parent's Names (if minor):


Email address
As per Canada’s Anti-Spam Legislation (CASL) I consent to receiving electronic messages for promotions and periodic updates only, to the email address above:
YesNo


Occupation
Physician's Name and Contact:


Emergency Contact
Contact Phone#


Health Coverage/Direct Billing Information(If Applicable)

Primary Coverage information:

Insurance Company:
Name of Insured:


Relationship: Insured MemberSpouseChild/DependentN/A
Group/Plan Number:


ID Number:



Secondary Coverage information(If Applicable): NOT ALL insurance companies support secondary direct billing - In these instances, secondary coverage must be submitted manually by client.

Insurance Company:
Name of Insured:


Relationship: Insured MemberSpouseChild/DependentN/A
Group/Plan Number:


ID Number:


General Information

What are your chief complaints?

Do you have, or have you ever had:

please specify other:



** only for female : Is there any chance of pregnancy at this time? YesNo

Please specify where you are experiencing pain:

Previous Medical History (previous illness, surgeries, traumas, illness in childhood)

Allergies

Family History of Health Problems

Current Medication (name, dose, frequency taken, for how long, reason)
***** blood thinner, ASA (aspirin for heart condition)


Current Supplements (name, dose, frequency taken, for how long, reason)

*** Do you have any amalgam(silver) fillings?

Life Style

Living Environment:

Favorite taste

Major sources of food

How often eating out (restaurants,fast food restaurant)?
Coffee (sugar, how many cups a day?
Tea (what kind?



Do you use any of the following?

What is your major sources of stress?

Your recent major emotion:

Please comment on your level of exercise (type & frequency)

Signs and symptoms

General Energy:


(scale: /10)



Fever and Chills:

Sweating:

Head and Body:

Chest and Abdomen

Face, Teeth, Ears and Eyes

Thirst

Appetite

Sleep

Urination

Bowel movement

Sexual Function

  • Sexual Energy
  • Male

Menstruation

  • Cycle
  • Volume
  • Colour
  • Property
  • Leukorrhea
  • Other

Pregnancy and Delivery

AUTHORIZATION FOR TREATMENT

I understand the nature of the treatment provided by Dr. Wang , and agree to work with her to attain my optimum health. I will provide as much background information as necessary and I realize that this information is confidential and is strictly used for the benefit of my treatment. I understand the fee policy of treatments I will receive. Fees are due when services are rendered and I am responsible for payment. A fee will be charged for appointments missed or cancelled without 24 hours notice.

Alberta acupuncture legislation states that an acupuncturist must not treat someone who has not consulted with a physician, or in the case of dental pathology, a dentist, about the condition for which s/he is seeking care and treatment. Therefore, please choose the applicable box confirming that you have already seen a physician or will be seeing one within two weeks of your first acupuncture treatment.

Please accept these before submitting form:

  • I have already seen a doctor regarding the condition(s) that I am seeking treatment for.
  • I agree to see a doctor regarding the condition(s) that I am seeking treatment for within two weeks of my first acupuncture treatment at Euphoria Wellness Centre.


Waiver (Please read carefully and sign)

I attest that the information I have provided is true and complete to the best of my knowledge.

  • I consent to treatments by Massage Therapists at Euphoria Wellness Centre.
  • I understand that I am responsible for any charges incurred in the course of my treatment.
  • I understand 24 hours notice is required to reschedule all appointments, or charges will apply.
  • I understand that No refunds are available on gift cards or massage packages. Packages cannot be combined or exchanged with other offers. Gift cards and packages are non-transferable.
  • I release the practitioner from any and all liability from problems arising from the treatment as a result of information given or not given, or incorrectly given in this history form. Because my personal and medical information is confidential, I understand that none of this information will be shared unless I give my consent in writing.
  • For my own safety and for the safety of the public: Intoxication (alcohol use or otherwise) will not be tolerated. Practitioners and/or Management have the right to refuse service should any signs of intoxication be present (eg. odour, slurred speech, belligerence, etc.) before or during my treatment. The full cost of the treatment will be charged to my account.
  • I, (print name) hereby fully understand the acupuncture treatment process and the possible effects such as:
    • fainting
    • small bruises
    • post-acupuncture sensation (numbness, tingling, heaviness, and tiredness
    • temporary exacerbation of symptoms

I agree to fully disclose all past and current health conditions. I shall give consent to have acupuncture treatment.


Client Signature:
Date:


Parent/Guardian Signature (if client under 18 years of age)