Initial consultation form (Acupuncture with Josephine)

ACUPUNCTURE CONSULTATION FORM

All the information that you provide in this form are strictly confidential. Please write N/A when a question is not applicable to your situation. Many thanks for your cooperation.
1. Personal details
Name *

First Name Last Name
Email address *
Phone number
DOB *
Occupation
HOW DID YOU HEAR ABOUT US? *

Google search Treatwell Classpass Word of mouth Other
2. Main Complaint
What is it? Can you describe it? What does it feel like? (Quality, Own words) *
When did it start? What was happening at the time?
Frequency? Continuous vs intermittent if so, how frequent?
Where is it located? (if physical)
Intensity? (dull/strong) When is it worse/better? (Time of the day, with/without movement, season, hot/ cold, climate, food/drink, lifestyle, stress)
Any accompanying symptoms? Any other complaints?
Any Diagnosis/Receiving other treatments/taking medication?
How does this prevent you? What can't you do as a result? How would you like acupuncture to help you? How has it helped so far?
3. Systems
SLEEP: Depth, how feel on waking, times, insomnia (waking in night, early, can't fall asleep, reason), sweat? Sleeping pills, dreams (intensity, recurring sleepy and heavy after eating?
FOOD APPETITE: (bad, good, can't eat), cold/hot, taste preference/ craving, taste (bitter, sweet, salty), when/ what eat daily?
DRINK: How much fluid per day, thirsty? Desire to drink, hot/cold, alcohol (how much, when, what, problems? Smoking? Drugs?
BOWELS: Regular, daily, consistency (either diarrhoea/ constipation qualities (colour), how often), pain (relieved by hot/cold), blood, undigested food, worse/better after
URINE: Amount, frequency, light/ dark/cloudy/blood, strong/ no smell
TEMPERATURE & SWEAT: How much, when (day/ night/exertion), hot/cold, area
MENSTRUATION: Regularity, short/long cycle, colour, quantity, clots, flow, pain, type, emotional changes, age when started, discharge (colour, smell)
PREGNANCY & CHILDBIRTH: How many. any problems (miscarriages, infertility, type of birth, post-birth) menopause: what age, problems? Flushes, emotional changes, lack of energy. Pill/coil?
HEADACHE: onset, time of day, location, type of pain, better or worse with pressure/movement/day/
DIZZINESS: Acute/chronic, strong or light, better/worse
EYES: Normal/short sighted, blurred vision, irritations, dryness, floaters, pain
EARS: Quality, tinnitus (onset, character, noise deep/high)
4. Family health & Personal History
BIRTH: What kind, premature, health when born, planned
EARLY CHILDHOOD: Breast fed, rashes, digestion, Healthy? Chickenpox, measles, whooping cough any particular/recurring illness?
OTHER PAST ILLNESSES: Accidents, injuries, operations broken bones, hospitalisation
FAMILY PARENTS & SIBLING: (alive?), health problems, illnesses, relationship with them/ each other?
ENJOYED CHILDHOOD? TEENAGE YEARS? SCHOOL? : Made friends easily? Mental, emotional strains in childhood? (teens, job, college)
PRESENT SITUATION: Living, housing (damp?). work, relationships, children, friends
5. Consent to treatment
Certain examinations or procedures, which form a normal part of therapy may be invasive in nature and may involve sensitive parts of the body. To ensure there are no misunderstandings between practitioner and patient, the practitioner will give a full explanation of any procedures prior to treatment commencing.

I understand that my medical records will be handled and stored according to the Data Protection Act (1998).

I will answer all questions relating to my medical history and lifestyle correctly and to the best of my ability.

I understand I will have a clear explanation of the treatment and possible side effects, including superficial bleeding and bruising from areas particularly rich in blood.

I understand I can request to stop treatment during procedure.

I will make sure that I am satisfied with the safety and hygiene COVID measures put in place.

I consent to having a course treatment.
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Date *
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ACUPUNCTURE CONSULTATION FORM

1. Personal details

2. Main Complaint

3. Systems

4. Family health & Personal History

5. Consent to treatment