Welcome to Victoria's Acupuncture and Wellness Clinic. I am a wellness practitioner who specializes in Acupuncture treatments and other alternative therapies to help you achieve optimal health and wellness. Please fill in this form to the best of your ability. If you are unsure or do not wish to disclose any information please feel free to leave blank unless it is required.
Acupuncture Intake Form
Name
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First Name
Last Name
D.O.B
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Email
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example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Doctors Surgery
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In some cases I may need to contact your GP, I will always discuss this with you first. Do I have your consent to correspond with your GP or appropriate services?
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Emergency Contact Name and relationship
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Emergency Contact Number
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Occupation
Medical History: accidents, injuries, operations, illness - include dates where possible
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Are you aware of any trauma that you may have experienced? If comfortable doing so please give a short description: Including age, duration, and nature of.
Have you any mental health conditions? Please give details:
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Have you received or are receiving any help regarding your mental health? These could be voluntary charities, therapists, or referrals. Please include services, the dates started, and the duration you received these services. Did you find any helpful?
Does any of your family suffer or has suffered from any mental health issues?
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Have you any addiction? If yes: What are the substances? How long have you been using each substance? How Frequently do you use each substance?
Have you been diagnosed with an ongoing illness/condition? What was the diagnosis? Do you know when it first started? Has it got better or worse?
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List all medications received for these conditions: How long have you been taking these? What is the dosage? How often do you take these?
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What is the main complaint? Please describe in as much detail as possible including when it started, what caused it (if known), where in the body it is felt, and what are the sensations associated with it e.g. pain, tingling, stiffness, numbness, twinging, fullness, weakness, swelling.. etc
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If there is pain, please describe the type of pain: Sharp, boring, aching, shooting, dull, constant, intermittent, and what makes it better/worse.
On a scale of 0-10 what is the severity?
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Please in your own words inform me of how this affects your life.
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Please list any exercises or relaxation/stress management (include frequency): Is there anything that makes your condition worse or better?
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Please tell me a little about your sleep patterns: Do you have trouble falling asleep or waking during the night? Do you have reoccurring or vivid dreams that either disturb your sleep or have a lasting impact on waking hours? Any sleepwalking? Bedwetting? Excessive talking in sleep? Apnoea? Or any other sleep-related condition?
Digestion: do you suffer from any of the following:
Bloating
Diarrhoea
Loose Bowels
Acid Reflux
Bitter taste
Foul smelling stools
Flatulence
pain relieved when emptying bowel
Pain relieved when passing stools
Constipation
Pain or discomfort in the abdomen
sour tatse
sugar cravings
mucus in stool
blood in stool
If yes to any of these, please use this box to expand the details:
Respiratory: Do you suffer from any of the following:
difficulty breathing
Asthma
Blocked nose
Sinus congestion
Short of breath
Cough
Allergies / hayfever
Post nasal drip
Throat irritation
Blocked feeling in throat
Phlegm
Other
If yes to any of these, please use this box to expand the details:
Cardiovascular: Do you suffer from any of the following:
Palpitations
Pins and needles
High blood pressure
low blood pressure
Blocked arteries
Stroke
Diagnosed Heart Disease
Numbness
DVT
Varicose Veins
Dizziness
DVT
Pain in Chest
Other
If yes to any of these, please use this box to expand the details: Please include the onset, and the duration, if it is relatable to a specific activity. How do you experience this when it comes on?
Urination: do you suffer from any of the following:
Incontinence
Pain passing urine
Urination at night
Urgency
Dark Yellow colour
Urgency with pain
Pale straw colour
Burning sensation
Prostate Conditon
Diagnosed UTI
Cystitis
Kidney Diseases
Other
If Yes please to any of these, please use this box to expand the details:
Head: do you suffer from any of the following:
Headaches
Dizziness
Ringing in ears
Irritated eyes
Red eyes
Weepy eyes
Fainting
Other
If Yes to Headaches: Where on the head do you feel this? What type of pain is this? Sharp, dull, boring, shooting, migraines, is your eyesight affected? Sensitivity to light? Is there a particular time of day/night? How long does it last? Constant, intermittent? Is this experienced with any other symptom, such as ringing in the ear, dizziness, nausea or other?
If yes to Dizziness: How is this experience? How long does it last? Is there a specific time of day/night? Is there a relative activity? Is your eyesight or hearing affected? Is it experienced with any other symptoms headaches, ringing in the ear, nausea or other?
If Ringing in the ear: Which ear? Is it low in pitch or high in pitch? Pulsating or continuous? Is there a specific time of day/night or relative activity that brings it on? Is this experienced with any other symptoms, headaches, dizziness, nausea?
If yes to any of these, please use this box to expand the details:
Do you have any pain/discomfort in any part of the body, please describe in as much detail as possible, when/where, dull, sharp, throbbing, stiffness, loss of strength, tightness, cramps, numbness, swelling, sweatiness etc: constant/intermittent, particular time of day? Is there anything that makes this better or worse?
Do you experience any heat/cold in the body, back, back of knees, hands, feet, arms, legs, or torso please describe in as much detail as possible:
Menstruation: Are you menopausal or perimenopausal?
Have you been diagnosed with any women's health-related conditions? Please give as much detail as possible, the diagnosis, onset etc
Do you track your cycle?
Is your cycle regular, short, or long? Please note how long your cycle is:
How many days is your bleed?
Are your periods heavy, scanty or normal?
Do you experience any clotting?
Do you experience any heavy discharge or unusual colouring of:
In there any pain associated with your cycle? please inform me of what stage and the severity.
Do you experience any PMS symptoms: bloating, breast extension, moodiness, irritability, anger, sadness: Do you experience menstruation headaches, nausea, vomiting: Do you experience backache or pain anywhere that's associated with the cycle?
Hair / Skin / Nails, please specify in as much detail as possible if you have any ailments, such as dry skin, skin problems such as eczema/psoriasis / acne, cracked nails, ridged nails, alopecia, dental issues etc:
Please describe your diet, typical breakfast, lunch, dinner, water, caffeine, alcohol consumption, snacks etc:
Please include anything you wish as extra notes or expand upon anything asked:
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