New Client Medical History Form

Acupuncture Intake Form

The following questions relate to your current and previous health condition and will take approximately 15 minutes to complete. Please ensure you complete all the fields marked with an asterisk *. The more information I gather the easier it would be to establish a TCM diagnosis.

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 *.
Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Post Code
Birth Date*

DayMonthYear
E-mail*
example@example.com
Mobile Phone Number*
How did you hear about us?*
If you were referred, who can we thank for referring you?
Full name please
Your Occupation
Emergency Contact*
Name & contact number
Allergies
Medications
Prescribed & supplements/herbs
Have you ever had Acupuncture before ?
If so when was the last acupuncture appointment?
If you have children, pls list their sex and age
Age, sex
Who is your General Practitioner (Doctor) list name and address ?
Full name & suburb
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.
Have you ever been diagnosed with any of the following?

AsthmaDiabetesCancerHepatitisEpilepsyHIV/AIDsTuberculosisMultiple SclerosisPolioLeukaemiaMental health illnessHeart DiseaseHigh Blood PressureHigh CholesterolDepressionAnxietyPTSDIBSAlzheimer'sAutoimmune disease
Main complaint - Please specify*
Describe the onset of the main complaint, when has it started, any accompanying symptoms, what is the process.
What medical testing have you had for this condition? What were the results?
At what time of day is the pain or discomfort at its worse?

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

ConstantOff/OnAt RestWith ActivityOther
Type of pain ie stabbing, throbbing, shooting, tingling, burning, dull, aching, heaviness, weakness etc
On a scale 1-10 how would you rate the severity of pain?
Sliders with calculated result
What makes the condition better*
What makes the condition worse*
Past operations, accidents, injuries, trauma- include dates*
Please specify including date
List all related treatments received for this condition.
What activities/hobbies do you enjoy doing?
Please list any exercise or relaxation/stress reduction activities you do (including frequency)
Please indicate if you see any other healthcare practitioners from the list below?

ChiropractorNaturopathOsteopathKinesiologistPhysiotherapistExercisePilatesReikiNutritionistMassage therapistGPPsychoterapistOther
Please check any symptoms that apply to you and use the Other category to add symptoms not listed.
Digestion & Bowels

BloatingPain or discomfort in the abdomenDiarrhoeaGas/windLoose bowelsConstipationAcid refluxSour tasteBitter tasteSugar CravingsPain relieved with emptying bowelCramping painPain relieved with passing windDiscomfort below navelAre you on a special diet? If so, please specify in 'Other'Other
How frequently do you open your bowels and is there any pain on passing, have you noticed any mucus or blood in your stools?
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 streamUrination at nightDark 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 periodsAmenorrhea (menstruation abscent)Heavy periodsPain or crampingCongealed blood (Clotting)Nausea/vomitingPain medicationHeadacheBack painChange bowelsLaproscopyD & CEndometriosisPCOSHormone TestsAnxietyDepressionSpottingUsing IUD or Contraceptive PillOther
What age did you first start menstruating?
How long is the period?
How many days is your period cycle? (how many days between the periods)
What is the colour of discharge at the start of your period?
red, dark red, brown
Have you ever been pregnant?
Each pregnancy, date
Have you ever had a miscarriage or termination?
When, Date
Are you currently trying to get pregnant?
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 the legLeg crampsNumbness in toesFeet feel coldPin & NeedlesCramps in footSwollen footPain in the kneeDiagnosed ArthritisKnee SugerySweaty feetInjuryOther
Hip

Pain in buttocksPain on side of hipPain in hip joinDiagnosed bursitisDiagnosed arthritisPain SIDE of legPain in buttocksPain BACK of legSurgeryInjuryOther
Consent Form
Informed Consent for Acupuncture Treatment
I hereby agree and consent to the performance of acupuncture and other Oriental Medicine procedures. I understand that such procedures may include: acupuncture, vessel pricking, acupressure, electro acupuncture, moxibustion, cupping & Gua-Sha, laser pen, advice on exercise therapy and nutritional counselling based on traditional Chinese medical theory.
Acupuncture practiced by a properly trained practitioner is a very safe therapy. Serious side effects from treatment are very rare – less than one per 10,000 treatments. The needles used are single-use, sterile, disposable needles. Your practitioner will follow strict guidelines laid down by the Association of Acupuncture Clinicians and developed by the leading experts in the field of skin piercing.
What are the possible side effects of acupuncture? You need to be aware that:
• Drowsiness can occur in a small number of patients, and if affected, you are advised not to drive.
• Minor bleeding or bruising can occur from acupuncture (in about 3% of treatments).
• Pain during treatment occurs in about 1% of treatments.
• Symptoms may become worse before they improve for 1-2 days following treatment. Please advise your acupuncturist if your symptoms feel worse and continue for more than 2 days
• Although rare, fainting can occur in certain patients, particularly at the first treatment. Please make sure you have a light meal/snack prior to the treatment.

I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. Acupuncture treatment is not a replacement for diagnostic medical procedures. An acupuncturist does not diagnose according to Western medical practice, nor should a “Chinese Diagnosis” be considered a replacement for standard medical evaluation or testing.

Apart from the usual medical details, it is important that you let your practitioner know:
• If you have ever experienced a fit, felt faint or had a funny turn.
• If you have a pacemaker, or any other electrical implants.
• If you are pregnant.
• If you have a bleeding disorder or are taking anti-coagulants or any other medication.
• If you have damaged heart valves or have any particular risk of infection.
• If you experience any unusual symptoms after treatment, or if you are concerned about any aspects of the treatment you have received, please contact your practitioner as soon as possible.
Moxibustion is the application of indirect heat by burning a stick of compressed Folium Artemisiae vulgaris, commonly known as Mugwort, over acupuncture points. Possible side effects are discolouration of the treated area or small blistering. It is contraindicated in cases of fever, acute infectious disease.

Cupping utilizes round suction cups over a large muscular area (such as at the back) to enhance blood circulation to the designated area. Bruising-like changes on skin, or small blistering may appear and last up to a week to subside. It is contraindicated for cups to be used on inflamed skin, any skin lesions, veins, arteries, varicose veins.

Gua-Sha is a form of Chinese massage in which an oil is applied on the skin a single use metal tool is being used to apply pressure and move down the muscles/along the acupuncture meridians to relieve pain and tension. This action may cause light “bruising like”, which often appears as purple or red spots known as petechiae or “sha” The discolouration normally clears within a week. It is contraindicated on inflamed skin- rosacea, eczema, severe acne breakout; sunburn, patient on blood thinners.

Electroacupuncture is a form of acupuncture where a small electric current is passed between pairs of acupuncture needles. It is contraindicated for patients with cancer and sever heart disease.

Ear seeds/ Press needles- these can be left on acupuncture points for few days. These need to be used with caution in patients with poorly managed diabetes, poor circulation, cauliflower ears, patients on blood thinning medication. If you feel unwell or there any symptoms such as rash, reddening and itching those should be removed. Marks may remain on the skin after plasters are removed, they should disappear after few days
By signing the consent you are also subscribing to my seasonal newsletter with some TCM explanations and suggestions for the coming season; as well as email reminders. You can always unsubscribe from them.

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 and that 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 and for any future condition(s) for which I seek treatment.
Name

First NameLast Name
Please sign your initials that you have received and understand our policy:*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Data Protection:
Holistic Therapy Ealing is legally required to record essential clinical information that we take from you during the initial consultation and each subsequent appointment to enable us to make an accurate diagnosis of your problem(s) and to formulate an appropriate treatment and management plan. These records are held on paper, not in electronic form, and you may request a copy at any time. Copies of any medical correspondence are stored in paper form and kept in a locked filing cabinet, accessible only to therapist at the Holistic Therapy Ealing. Statutory minimum storage times for medical records and associated correspondence are seven years after the date of the last appointment. In the case of minors records must be kept until the patient reaches the age of twenty-five (seven years after reaching eighteen). Holistic Therapy Ealing may contact you with regards to your treatment plan, send you discussed materials, reminders, seasonal newsletter or offers.
Please note that once you have booked an appointment with Holistic Therapy Ealing, it means that the time has been reserved exclusively for you. If you cancel your appointment less than 24 hours before it is scheduled to take place, you will be liable to cover the appointment fee. If you feel sick and unable to attend the appointment please do let me know ASAP so I can offer your appointment to a patient from a waiting list. You can cancel or reschedule an appointment by emailing info@holistictherapyealing.co.uk or texting 07899737421. No Shows will be charged the full treatment amount and must be paid before another appointment can be booked.

By signing the below, you are acknowledging that you have read and accepted this Data Protection Policy & Cancellation Policy and give consent to the practitioner to maintain records for the purpose outlined within the policy, as well as use your contact details to keep in touch.
Name

First NameLast Name
Signature

Clear
Should be Empty: