Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Do you have private health insurance?
Yes
No
Who is your Health Insurance provider?
How did you hear about Ford Acupuncture?
One of our current patients
Google Search
Google Maps
Google Ad
Word of Mouth
Walking past
Flyer
Facebook
Instagram
Other
What did you hear about Ford Acupuncture?
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Main Reason(s) you are coming in to Ford Acupuncture?
How long has this/these been a problem for you?
Have you been given a professional diagnosis for this problem(s)? If so, what , and by whom?
What kind of treatments have you tried for this problem(s) and which are you persisting with and why?
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Have you had Acupuncture or East Asian Medicine before?
Yes
No
Where did you get Acupuncture (which business/acupuncturist)?
If yes, what was your experience? What did you like about it? What did you NOT like about it?
What is your expectation or goal from attending Ford Acupuncture?
On a scale of 1-10, how committed are you to correcting the problem(s) that are affecting your health?
1=not committed, 10=will do anything to get better
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What is your occupation?
How many hours a week are you working?
What do you do for fun? Hobbies/sport/recreational activities?
Do you have a regular exercise program?
Yes (please provide details below)
No
Details of exercise program:
Do you smoke or vape?
Yes
No
Occasionally
If you smoke/vape, how many cigarettes/sessions a day?
Do you drink alcohol? How regularly? What type (beer, red wine, white wine, spirits with mixers or straight spirits)?
Do you drink coffee? If yes, how many per day?
1 coffee
2 coffees
3 coffees
4+ coffees
I don't Drink Coffee
Please list what sort of tea you drink:
Please detail if you drink sports drinks or energy drinks or soft drinks below include quantity and which ones you drink:
How much water do you drink every day?
Is your water?
Tap water
Filtered water
Type option Bottled water
Drunk from plastic bottles
Drunk from glass container
Sparkling water
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Are you allergic to any medications that you are aware of?
Do you suffer from any allergies?
Do you currently take any medications? Please list below if you are
Are you currently taking any supplements? If yes, please list below:
Are you currently taking any herbs?
Yes
No
Please list herbs/herbal formula as well as the reason for taking them:
please list any previous surgeries you have undergone including dates and surgical outcomes/complications:
Medical conditions past or present (please select any that apply to you)
Migraine
German Measles (Rubella)
Prolonged Dizziness
Eczema
Psoriasis
Acne
Herpes Zoster
Glasses/Contact Lenses
Thyroid Issues
Pneumonia
Tuburculosis
Asthma
Bronchitis
Other Lung Conditions
Heart Attack
Heart Murmer
Rheumatic Fever
Other Heart Condition
High Blood Pressure
Gastric/Duodenal Ulcers
Gastric Reflux
Hepatitis
Intestinal Bleeding
Bleeding Tendency (Bruise Easily)
Problems with Anesthesia
Diabetes Type 1
Diabetes Type 2
Kidney Stones
Kidney Infection
Other Kidney Disorders
Bladder Infection
Rheumatoid Arthritis
Other Forms of Arthritis
Lupus Erythematosus
Paralysis
Neurological Disorders
Thrombophlebitis
Varicose Veins
Obesity
Stroke
Other
Other (please list):
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Chinese Medicine
Please ensure you fill every question out in this section as this will greatly assist with your acupuncture treatment and treatment outcome. Please select all of the following symptoms that you have experienced in the past 6 months.
Lower back weakness, soreness or pain
Knee problems
Ringing in the ears or dizziness
Prematurely Grey hair
Dark circles under or around eyes
Night sweats or hot at night
Prone to hot flushes
Experience fear in your daily life
Lower back pain premenstrually
Cold feet and hands
Typically feel colder than those around you
Low libido/sex drive
Wake up frequently at night to urinate
Frequent urination and this urine is light in colour
Woken by loose bowels
Feel tired after ejaculation/sex
Often feel fatigued
Energy is lower after eating
Often feel bloated after eating
crave sweet food
Often have digestive issues or abdominal pain
Nose often feels cold
Heaviness or foggy feely in your head
Bruise easily
poor circulation
Prone to worry
Been diagnosed with low blood pressure
Sweat a lot without exerting yourself
Often feel lightheaded or dizzy or have visual changes after standing up
Often sick or have allergies
Haemorrhoids, polyps or prolapse
History of Anaemia
Dry, flaky skin
Psoriasis or eczema
Chapped lips
Brittle fingernails or toenails
Hair loss on your head
Diminished night time vision
Experience dizziness or lightheadedness
Shortness of breath
Heart palpitations (feel your heart beating in you chest)
Periodic numbness
Varicose veins or spider veins
Lower abdominal pain or tenderness on palpation (when touched)
Dark spots in vision
Stabbing, fixed pain that you can pinpoint the location of
Prone to emotional depression
Prone to anger or quick to fire or rage
History of being diagnosed with high prolactin levels
Difficulty falling asleep at night
Heartburn or wake up with a bitter taste in your mouth
Unexplained pain under your ribs, chest or abdominal region
Frequently sighing
Regular belching or passing of gas regularly
Tight neck and shoulders
Stressed about work
Stressed at home
Highly stressed
Headaches at the top of your head
Headaches around temples
Rapid pulse rate
Often have a dry mouth and throat
Thirst for cold drinks most of the time
Often feel warmer than those around you
Wake up sweating or have hot flushes
Break outs with red acne
Face and eyes turn red easily
Acid regurgitation
Experience constipation
Red skin rashes
Concentrated (yellow) urine
Smelly urine
Restless leg syndrome
Feel tired and sluggish after a meal
Cystic or pustular acne
Urgent, bright or mould smelling stools (poo)
Fibrocystic breasts
Joints that ache, especially with movements
Overweight
Often have damp, sticky (stick to the toilet bowl or need to use lots of toilet paper), unformed stools
Crave sweet food
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Musculoskeletal Conditions
If you are seeking treatment for musculoskeletal issues please fill out the following questions, if not please move forward...you're almost finished :)
Where in your body is your pain or discomfort located?
When did this start?
What is the cause of this (only if known)
Can you best describe what discomfort you feel?
Is this a recurring problem?
Does the pain Stabbing or Aching? Or does it alternate between these?
Does the pain move or is it in a fixed location?
What makes the pain BETTER? Movement? Heat? Cold? Pressure?
What makes the pain WORSE? Movement? Heat? Cold? Pressure?
Have you sought help for this elsewhere? If so, by who and what modality? What was your experience and outcome?
Is your condition worse with stress?
On a scale of 1-10 what do you rate the pain on a good day? 10= excruciating, debilitating, can't move or get out of bed 1=occasionally I'll feel it but doesn't bother me
On a scale of 1-10 what do you rate your pain on a bad day? 10= excruciating, debilitating, can't move or get out of bed 1=occasionally I'll feel it but doesn't bother me
Do you experience any loss of function or mobility due to your pain?
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Informed Consent
Please read carefully and sign at the end
I have read and fully understand all of the above. I have answered all the questions accurately and truthfully to the best of my knowledge and will discuss any further questions and concerns that I may have with my practitioner at my initial consultation. *
Yes, I agree
Signature
Name
First Name
Last Name
I am unable to electronically sign and will sign the Informed Consent Form at my initial consultation:
Yes, please
Submit
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