Jacina Facial Acupuncture Form 2020

1
Please answer this as honestly as possible. This information is confidential.
2
Name
First Name
Last Name
3
Email
example@example.com
4
Address
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number
Area Code
Phone Number
6
Age?
7
DOB
Date
Year
Month
Day
8
Emergency contact name & their relationship to you
9
Are you pregnant or trying to conceive?
YESNO
10
Have you had acupuncture before?
YESNO
11
Do you bruise easily?
YESNO
12
Are you taking cod liver oil as a supplement?
YESNO
13
Please describe your skin care routine
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Ok
14
Do you wear sunscreen?
YESNO
15
Do you have a healthy diet?
YESNO
16
Please describe a typical day's food. Breakfast, lunch and dinner.
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Ok
17
How many snacks do you have a day and what kind of snacks?
18
What areas of your face are you wishing to improve?* This field is required.
Eye area
smile lines
forehead
11'es
jaw line
crows feet
not listed
19
Please can you describe the main reason for your visit.
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20
Have you had any recent Botox, fillers or plastic surgery? Please note months and years and areas. Mention if you have had any complications or reatctions?
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Ok
21
Have you ever had any adverse reaction to any treatment or facial treatmente.g. every time I go to the dentist I faint.
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Ok
Ok
22
Have you ever had any of the following health conditions
no
past
current
in my family
Heart Conditions
Diabetes
Respiratory Conditions
HIV/AIDS
TMJ / Jaw Pain
Skin Condition
Thyroid Condition
PMS
Stroke
Deep Vein Thrombosis
Kidney Disorder
Sprain/Strain/Fracture
Arthritis
Digestive Issues
Epilepsy
High Blood Pressure
Low Blood Pressure
Cancer
Neurological Issues
Osteoporosis
Dizziness/ Fainting
Haemophilia
Multiple Sclerosis
Spinal/ Head Injury
Hepatitis
Headaches/ Migraines
Contagious Illness
Wearing a Pacemaker
Endometriosis
Upcoming surgery?
Are you Pregnant?
Heart Conditions
Diabetes
Respiratory Conditions
HIV/AIDS
TMJ / Jaw Pain
Skin Condition
Thyroid Condition
PMS
Stroke
Deep Vein Thrombosis
Kidney Disorder
Sprain/Strain/Fracture
Arthritis
Digestive Issues
Epilepsy
High Blood Pressure
Low Blood Pressure
Cancer
Neurological Issues
Osteoporosis
Dizziness/ Fainting
Haemophilia
Multiple Sclerosis
Spinal/ Head Injury
Hepatitis
Headaches/ Migraines
Contagious Illness
Wearing a Pacemaker
Endometriosis
Upcoming surgery?
Are you Pregnant?
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
no
past
current
in my family
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23
Please Elaborate any of the above here with dates and summary
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24
Please describe any surgeries in the last 5 years.
25
Please note any of the following: prescription medication, over the counter medication or any other herbal or supplements you are currently taking.
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Ok
26
Any Allergies (food, drugs, environmental)?
27
Do you smoke? If so how much and how often?
28
Do you drink alcohol? How many units and how often?
29
What is your daily intake of caffeine?
30
Fizzy drinks?
31
Recreational drugs?
32
Do you exercise? If so how often and what kind of activities
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Ok
33
Have you had acupuncture before?
YESNO
34
What other kind of treatments do you do?
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Ok
35
Do you have broken or ulcerated skin?
YESNO
36
Do you have a history of cold sores?
YESNO
37
Do you bruise easily?
YESNO
38
Do you sunbathe or use sun beds regularly?
YESNO
39
Do you have keloid scars/ moles or warts?
YESNO
40
Any skin allergies? If so when?
41
Have you seen a dermatologist? What was the reason?
42
What is your current skin care routine?
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Ok
43
Can you rate your current energy levels out of 10?
Please enter a number
44
Energy Levels
45
Liver - GanLeaver blank if not applicable
Often
sometimes
occasionally
Irritability
Frustration
Depression
Stress
Emotional Eating
Unfulfilled desires
Blurred/ poor night vision
Red/ dry / itchy eyes
Headache / migraines
Dizziness
Feeling of lump in throat
Muscle twitching spasm
Neck / shoulder tension
Brittle nails
Sighing
Sensation / Pain under ribs
PMS
Genital itching, pain, rashes
Irritability
Frustration
Depression
Stress
Emotional Eating
Unfulfilled desires
Blurred/ poor night vision
Red/ dry / itchy eyes
Headache / migraines
Dizziness
Feeling of lump in throat
Muscle twitching spasm
Neck / shoulder tension
Brittle nails
Sighing
Sensation / Pain under ribs
PMS
Genital itching, pain, rashes
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
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Often
sometimes
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Often
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Often
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sometimes
occasionally
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46
Kidney - ShenLeaver blank if not applicable
Often
sometimes
occasionally
Frequent Urination
Bladder Infection
Loss of bladder control
waking at night to urinate
Feeling cold easily
Cold hands or feet
Night sweats / hot flushes
Low sex drive
High sex drive
Loss of head hair
Hearing problems
Craving salty food
Fearful
Poor long term memory
Ankle swelling
tinnitus
Frequent Urination
Bladder Infection
Loss of bladder control
waking at night to urinate
Feeling cold easily
Cold hands or feet
Night sweats / hot flushes
Low sex drive
High sex drive
Loss of head hair
Hearing problems
Craving salty food
Fearful
Poor long term memory
Ankle swelling
tinnitus
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
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Often
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Often
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Often
sometimes
occasionally
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47
Lung - FeiLeaver blank if not applicable
Often
sometimes
occasionally
dry cough
phlegmy cough
nasal discharge /drip
sinus infection /congestion
itchy painful throat
dry mouth / nose / throat
skin rashes / hives
snoring
grief / sadness
shortness of breath
allergies / asthma
weak immune system
alternate fevers / chills
dry cough
phlegmy cough
nasal discharge /drip
sinus infection /congestion
itchy painful throat
dry mouth / nose / throat
skin rashes / hives
snoring
grief / sadness
shortness of breath
allergies / asthma
weak immune system
alternate fevers / chills
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
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Often
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Often
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Often
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48
Heart - XinLeave blank if not applicable
Often
sometimes
occasionally
Palpitations
Chest pain / tightness
Insomnia / sleep problems
Restlessness
Easily agitated
Vivid dreams
Lack of Joy in life
Forgetfulness
Aversion to heat
Bitter taste in mouth
Tongue/ mouth ulcers
Palpitations
Chest pain / tightness
Insomnia / sleep problems
Restlessness
Easily agitated
Vivid dreams
Lack of Joy in life
Forgetfulness
Aversion to heat
Bitter taste in mouth
Tongue/ mouth ulcers
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
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Often
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Often
sometimes
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Often
sometimes
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Often
sometimes
occasionally
Often
sometimes
occasionally
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49
Stomach - PiLeave blank if not applicable
Often
sometimes
occasionally
Heavy head /body
fatigue after food
difficulty waking up
water retention
muscle tiredness / weakness
bruise easily
unusual bleeding nose /stools
bad breath
poor appetite
increased appetite
sweet cravings
poor digestions
nausea / vomiting
bloating / gas
haemorrhoids
constipation
loose stools
alternate loose stools constipation
abdominal pain
intestinal pain / cramping
heartburn
pensive / overthinking
overweight
foggy mind
yeast infection
aversion to cold
cold nose
increased thirst
prefer warm drinks
prefer cold drinks
sweat easily
Heavy head /body
fatigue after food
difficulty waking up
water retention
muscle tiredness / weakness
bruise easily
unusual bleeding nose /stools
bad breath
poor appetite
increased appetite
sweet cravings
poor digestions
nausea / vomiting
bloating / gas
haemorrhoids
constipation
loose stools
alternate loose stools constipation
abdominal pain
intestinal pain / cramping
heartburn
pensive / overthinking
overweight
foggy mind
yeast infection
aversion to cold
cold nose
increased thirst
prefer warm drinks
prefer cold drinks
sweat easily
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
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Often
sometimes
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Often
sometimes
occasionally
Often
sometimes
occasionally
Often
sometimes
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Often
sometimes
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Often
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Often
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Often
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Often
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Often
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Often
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Often
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Often
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Often
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Often
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Often
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Often
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50
what is your occupation / daily routine?
51
Bowels
yes
no
mixed
Do you have regualr bowel movements?
are they well formed
difficult to pass stools?
are you a light sleeper
Do you get 7 hours a night?
do you have vivid dreams?
do you wake in the night?
is is easy to get back to sleep?
Urinary frequency?
Any urinary urgency?
Urinary burning?
Urinary dribbling?
Urinary retention?
frequent UTI s?
Do you drink water through out the day?
Do you have regualr bowel movements?
are they well formed
difficult to pass stools?
are you a light sleeper
Do you get 7 hours a night?
do you have vivid dreams?
do you wake in the night?
is is easy to get back to sleep?
Urinary frequency?
Any urinary urgency?
Urinary burning?
Urinary dribbling?
Urinary retention?
frequent UTI s?
Do you drink water through out the day?
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
yes
no
mixed
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52
Do you enjoy what you do daily?
53
how often are you working?
54
Do you see daylight in your job / day to day?
55
Is you day to day stressful?
56
If you are stressed please specify why / who / where (personal or work)?
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57
Do you consider yourself to be in good general health?
58
How often have you taken either antibiotics or steroids in the last 5 years?
59
How much do you drink a day? Do you prefer warm or cold drinks? Do you sip or gulp?
60
Have you ever been diagnosed with any of the following?
STD
Polyps
Pelvic inflammatory disease
Pelvic Adhesions
Uterine fibroids
Prolapsed Uterus
frequent yeast infections
Any cervical biopsy /operations
Any abnormal smear
Is your smear up to date?
Endometriosis
PCO or PCOS
Had an IUD
Take or taken the Pill
61
About your periods
I am still menstruating
I think I am peri menopausal
I get PMS
I get pain before my period
I get pain during my period
I get paid after my period
the pain is stabbing
the pain is cramping
the pain is dull
the pain is heavy
the pain is on /off
62
Pre-menstrual Symptoms
breast tenderness
cramps
acne
bloating
headaches
change in bowel
nausea
moodiness
fatigue
night sweats
sleep disturbances
63
what relieves menstrual pain?
64
Have you ever suffered from depression?
YESNO
65
Have you ever had any medical diagnosis for mental health conditions? If so when.
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Ok
66
Have you ever had or suffered with suicidal thoughts?
67
Any paranormal activity experiences or significant life events that have left a mark?seeing ghosts
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Ok
68
Have you ever experienced any abuse or victimisation?
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Ok
69
Is there anything else you feel is important or relevant?
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Ok
70
If you took the Pill - for how long and when did you stop, or are you still taking it?
71
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