New Client Medical History Form

New Client Form

The following questions relate to your current and previous health condition and will take less than 10 minutes to complete. Please ensure you complete all the fields marked with an asterisk *.

All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *.
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Birth Date*

DayMonthYear
E-mail*
Mobile Phone Number*
Insurance provider - policy and ID number or contract number
How did you hear about us?*
If you were referred, who can we thank for referring you?
Full name please
Occupation
Emergency Contact*
Name & contact number
Allergies
Medications
Prescribed & supplements/herbs
Have you ever had Acupuncture before?
What is your outcome for your treatments?
Client Medical History

Please complete the following questionnaire to the best of your knowledge. Further questions may be asked by your practitioner regarding the information provided here.
Past operations, injuries & health history*
Please specify including date
Have you ever been diagnosed with any of the following?

AsthmaDiabetesCancerHepatitisEpilepsyHIV/AIDsTuberculosisMultiple SclerosisPolioLeukaemiaSARS/Bird FluHeart DiseaseHigh Blood PressureHigh CholesterolDepressionAnxietyPTSDIBSAlzheimer'sAutoimmune disease
1. Main complaint - Please specify*
2. Describe the onset of the main complaint*
3. What medical testing have you had for this condition? What were the results?
5. At what time of day is the pain or discomfort at its worse?*

MorningAfternoonEveningDuring SleepOther
4. Frequency of pain or discomfort - please select the most accurate*

ConstantOff/OnAt RestWith ActivityOther
6. Have you ever injured this area before?*
7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
8. List all related treatments received for this condition.
9. Have you ever received acupuncture for a specific problem or injury?
10. Is there anything that you do that increases or decreases discomfort or pain?*
11. What are the physical duties required of your occupation?*
12. What activities/hobbies do you enjoy?*
13. Please list any exercise or relaxation/stress reduction activities you do (including frequency)*
14. Please indicate if you see any other healthcare practitioners from the list below?

ChiropractorNaturopathOsteopathKinesiologistPhysiotherapistExercise PhsyiologistPilatesReikiNutritionistMassage therapistGPEnergy Balancing TherapistOther
15. Who is your General Practitioner (doctor)?
Full name & suburb
Please check any symptoms that apply to you and use the Other category to add symptoms not listed.
Digestion & Bowels

BloatingPain or discomfortPain above navelDiarrhoeaGas/windLower abdomenRight side abdomenLoose bowelsConstipationAcid refluxSour tasteBitter tasteSugar CravingsPain relieved with emptying bowelCramping painPain relieved with passing windPain under rib cageDiscomfort below navelLeft side abdomenAre you on a special diet? If so, please specify in 'Other'Other
Breathing & Sinus

Difficulty breathingAsthmaBlocked noseRinging in earsShort of breathDifficulty swallowingSinus CongestionNasal DischargeCoughThroat irritationPhlegmBlocked feeling in throatAllergies/HayfeverPost nasal dripNose SurgeryNose injuryOther
Heart & Blood Vessel Circulation

High Blood PressureDizzinessPain in chestPins and needlesLow Blood PressureDVTNumbnessVaricose veinsBlocked arteriesDiagnosed Heart DiseaseSurgeryPain radiates to armStrokePeripheral NeuropathyOther
Urination

IncontinencePain passing urineLong streamShort streamDark yellow colourOrange colourPale straw colourUrgency without painUrgency with painMore than once during nightBurning sensationMore than 5 times during daytimeProstate conditionDiagnosed UTICystitisKidney DiseaseOther
Skin, Hair, Nails & Dental

Dry skinCracked skin on fingersAcneCracked nailsRashRidges on nailsEczemaFungal infectionDermatitisAlopeciaPsoriasisDandruffToothacheGingivitisGum InfectionTooth Nerve pain (Root canal)Other
Menstruation

Irregular periodsAmenorrheaHeavy periodsPain or crampingDysmenorrheaCongealed bloodNausea/vomitingPain medicationHeadacheBack painChange bowelsLaproscopyD & CEndometriosisPCOSHormone TestsAnxietyDepressionSpottingUsing IUD or Contraceptive PillOther
What age did you first have your period?
How many days is your period cycle?
What is the colour of discharge at the start of your period?
red, dark red, brown
Head

Tension in templesDizzinessLight-headednessRinging in earsFaintingHeadachesAround eyesSinus Congestion/Nasal DischargeRed eyesIrritated eyesWeepy eyesOther
Neck

Disc herniationPain at base of neckPain when turningMuscle spasm in neckStiffnessNeck feels out of placeBone spursPain when moving side to sideTMJ DisorderArthritisInjuryWhiplashOther
Shoulders

Pain in shoulderFrontBackTopBursitisArthritisShoulder surgeryCan't raise arm above shoulder levelPain with activityPain wakes from sleepPain at restPain in morning on wakingOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersFingers go to sleepSensation of pins & needlesSwollen jointsSore joints in fingersDiagnosed arthritisLoss of grip strengthHands coldSensation referred down arm to handOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain around entire torsoPain along spineTight along sides of torsoPain with breathingRestricted movementOther
Low Back

Low back painPain is worse workingPain is worse liftingPain is worse standingPain is worse sittingPain is worse bendingPinched nervePain is worse coughingDisc herniationLow back feels out of placeArthritisSurgery
Legs and Feet

Pain down RIGHT legPain down LEFT legLeg crampsNumbness in toesFeet feel coldPin & NeedlesCramps in footSwollen footPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisKnee SugerySweaty feetInjuryOther
Hip

Pain in buttocksPain on side of hipPain in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisPain SIDE of legPain in buttocks in buttocks when sittingPain BACK of legPain in buttocks when standingSurgeryInjuryOther
How many children do you have?
Age, sex
Have you ever been pregnant?
Each pregnancy, date
Have you ever had a miscarriage?
When, Date
Are you currently trying to fall pregnant?
Clinic Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your mobile phone for optimal relaxation

• Your scheduled session is set aside for you. We do not double book appointments

• Please provide at least 24 hour cancellation notice to avoid being charged a cancellation fee 80%. Less than 24 hours notice will incur a cancellation fee of 100% of the scheduled fee

• You will have a consultation with your practitioner to discuss your session

Client Agreement:

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my practitioner. I have stated my pertinent medical conditions, and will update the practitioner of any changes in my health status.

I understand that my failure to do so may pose a threat to my health and/physical well being and I hold harmless Integrative Health Chinese Medicine Centre and my practitioner from any liability whatsoever arising from failure on my part.

Informed Consent to Treatment:

I hereby agree and consent to the performance of acupuncture and other Traditional Chinese Medicine procedures. I understand that such procedures may include, but are not limited to, acupuncture, moxibustion, cupping, gua sha (dermal friction technique), infrared heat lamp, electro-acupuncture, breathing techniques, exercise therapy, Tui-Na (Chinese massage), Do In Chinese or western herbal medicine, lifestyle, exercise and nutritional counselling.

Acupuncture is a technique utilizing fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using the compressed and ignited fiber of Artemesia vulgaris, commonly known as Mugwort. Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Tui Na (Chinese massage), Do In and Shiatsu (Japanese massage) are used in facilitating healing and pain management. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment.

I have been informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. I have been informed that acupuncture is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A hematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if I experience any symptoms or problems. I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable.

I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Chinese Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan.

This is NOT a waiver form. It is part of our "duty of care" to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections or collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility.

I will inform my practitioners immediately of any discomfort with this arrangement and steps will be taken to modify my treatment. By voluntarily signing below, I hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition. I have read this form, understand the information it contains, and give my consent to treatment. *
Please sign your initials that you have received and understand our policy:*

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