Acupuncture & Integrated Acu-Bodywork Client History Intake Form

Name: ______DOB: ______

Gender: ______Weight: ______

Height: ______

Address: ______City: ______

Postcode: ______

Tel home: ______Mobile: ______

Occupation: ______

Email address______

Emergency contact name & Tel no:______

How did you hear about the services at this clinic (tick all that apply)?

___ Personal recommendation ___ Health practitioner referral ___ Internet

Other______

Please provide your G.P’s contact details: ______

______

CURRENT REASON/S FOR CONSULTATION

Reason/s for today’s visit: ______

I am here for one of the following conditions: Weight control support_____ Detox support_____

Smoking cessation_____ Withdrawal from medication_____

How long have you had this condition? ______The onset was sudden_____gradual_____

How are your symptoms changing with time?Getting worse____ Staying the same____ Getting better___

Does anything bring it on or make it worse (rest/movement/hot/cold/carrying bags/ driving/

weather/diet/stress/time of day)?______

______

Does anything you do relieve it (eg: rest/movement/hot/cold/position/weather/diet)? ______

______

To what extent does this interfere with your daily activities (work/sleep/exercise regime/

mobility/appetite)? ______

______

Please detail any previous treatment and medication given, including self-administered (this includes exercises). Were they helpful? ______

______

What tests or investigations have you had, if any? ) Please give dates, the name and contact address of any treating practitioner and the results). ______

______

Sign here if you give permission for me to contact them in regard to your case______

Have you ever received acupuncture and /or Chinese herbal medicine before? ______

______

PERSONAL HEALTH HISTORY:

Please list all medication you are taking (including supplements) and for what conditions?

Please tick all that are relevant& give details where applicable.

Y N Allergies (food, latex, topical preparations, medicines)______

Y N Frequent use of antibiotics

Y N Addiction or substance abuse issues (medication, recreational drugs, alcohol).

Y N Have you recently been innoculated?______

Y N Have you flown in the last 48 hours?

Y N Do you have a pace-maker?

Y N Are you taking anti-coagulant medication?

Do you have:

Y N HIV/AIDS Y N Hepatitis A/B/C Y N Diabetes (type I/II)? Y N Haemophilia

Y N Tuberculosis Y N Herpes simplex Y N Contagious illness Y N Cardiac problems

Y N Hypertension Y N Low blood pressure Y N Deep Vein Thrombosis

Y N Circulatory problems (eg atherosclerosis/arteriosclerosis/varicose veins/pheblitis/Raynaud’s)

Y N Digestive problems(eg hernia/ulcer/acid reflux/colitis/Irritable Bowel Syndrome)

Y N Epilepsy or seizures Y N Kidney disorder Y N Skin condition

Y N Respiratory disorders (eg asthma/emphysema/bronchitis/pneumonia/cystic fibrosis)

Y N Thyroid disorders Y N Sprain/strain/fracture Y N Fibromalgia

Y N Bone or joint disorders (such as osteoporosis; osteoarthritis; rheumatoid arthritis;

gout; myositis ossificans or ankylosing spondylitis) Y N Spinal or head injury

Y N Joint replacements or metal pins or plates Y N Neurological disorders Y N Tumours/cancer/

melanoma

Other specify)______

List any major illnesses, disabilities, surgeries, accidents, significant trauma (emotional or physical such

as death or divorce) with year or age of occurrence

Childhood:
Adulthood:

YOUR FAMILY HISTORY

Please list any major family illnesses in your immediate family (e.g: diabetes; cardiovascular

conditions; respiratory disorders; neurological disorders; psychological disorders;

immune disorders; arthritis; prostate problems).

Parents
Siblings
Grandparents

Exercise & Energy

How much exercise do you do a week? Please list all sports/activities that you do: ______

______

Is your job active or sedentary? ______

How is your energy? ______

Dislike physical movement ___General physical weakness/ lack of strength ___ General fatigue___

Exhaustion___

What time of day is your energy: Highest? ______Lowest? ______

Diet Do you eat? Meat___ Dairy___ Fish___ Vegetables___ Artificial sweeteners___

Please list your average daily intake of cups of: Coffee___ Tea ___ Cigarettes: ___ Fizzy drinks ___

Water ___ Alcohol ___

How many meals do you eat in an average day? ______

Please list any food/s or taste/s which you have a particular craving for and dislike of______

______

Do you use recreational drugs? Y N

Emotions & Sleep Do you have?

Panic attacks ___ Depression ___ Anxiety___ Moodiness/anger ___ Nervousness ___ Poor memory___Poorconcentration ___ Sadness/Grief ___ Indecisiveness ___ Restlessness ___ Irritability___Impatience ___ Frustration ___ Fearfulness ___ Easily obsessive ___ Feeling hyperactive ___

Feeling spacey ___ Worrying ___ Mental exhaustion/burnout ___ Mental fatigue ___

Do you feel easily stressed? ______

How many hours do you sleep anight? ______

Do you sleep soundly? ______

Do you have? Difficulty falling asleep ___ Vivid dream/nightmares ___ Night terrors ___ Waking early ___ Difficulty waking___ Sleep heavily___ Light sleep/wake easily ___ Waking feeling fatigued ___Waking up at about _____am/pm and not being able to fall asleep again ___ Sleepwalking ___

Are you in a relationship? ______

How do you feel about your relationship? ______

How do you feel about your work? ______

Please rate your current stress level from 0 (none) to 10 (extremely stressed)

At home: ______At work: ______

What is your favorite season? ______Least favourite? ______

Muscles, Joints & Bones

Are you in pain or discomfort? Y N

Where do you feel it? ______

______

What time of day is it at its most discomforting?______

Is the pain constant or episodic? ______

Does the pain radiate to other parts and if so, where? ______

What does it feel like? Tick all that apply

Sharp ___ Dull ___ Aching ___ Heavy ___ Tingling ___ Stabbing ___ Throbbing ___ Shooting ___

Numb___ Deep ___ Burning___ Localised ___ Diffused___ Cramping___

On a scale of 1-10 (1 is slight discomfort, 10 refers to very severe) rate the pain in terms of severity.______

What other symptoms are you experiencing? Tick any that apply

Changes in sensation such as numbness or pins & needles___ Swelling___ Stiffness ___ Back ache ___

Muscle weakness___ Movement limitation___ Jaw pain ___ Changes in bowel or urinary function___ Difficulty walking ___ Achy knees ___ Body heaviness ___ Sciatica ___ Tremors ___

Indicate on the drawings below where you have pain/symptoms

Have you taken painkillers within the last 4 hours? Y N

I have or often have (tick all symptoms from the following lists that apply)

Head, Neck, Eyes, Ears, Nose, Throat Dizziness when standing up ___ Lack of co-ordination___

Fainting or feeling lightheaded___ Head stuffiness ___ Vertigo ___

Headache ___ If yes do you feel it: Front___ Temple/side of head ___ Back ___ Top___

Describe the pain ______

Hair: Dry ____ Brittle ____ Hair loss/thinning ____ Premature graying___ Dry scalp ____

Itchy scalp ____ Scaly scalp ____ Dandruff ____

Ear: Hearing loss ___ Tinnitus/ringing ___ Excessive wax ___ Ear pain___

Clogged/popping in ears___ Ear infections ___

Eye: Poor vision ____ Blurred vision ____ Poor night vision___ Eye pain___ Dry eyes ____

Gritty eyes ____ Itchy eyes___ Red/burning eyes___ Spots/floaters___ Cataracts ___

Nose: Runny nose ___ Nosebleeds ___ Stuffy/blocked nose ___ Itchy nose ___ Sinus congestion ___

Sinus infections ___Phelgm___ Nasal discharge: Clear ___ White ___ Yellow ___ Bloody ___

Thick ___ Watery ___

Mouth: Dry mouth ___ Bad/bitter taste in the morning___ Ulcers ___ Bleeding gums ___

Inflamed gums ___ Loose teeth ___ Tooth loss ___ Abcesses ___ Jaw ache ___Cold sores ___

Throat: Dry throat___ Itchy throat ___ Sore throat ___ Swollen glands___ Stiff neck___ Phelgm ___

Difficulty swallowing/ lump in throat ___ Feeling unable to speak ___

Respiratory Easily catching colds ___ Shortness of breath on exertion/at rest ___ Asthma ___

Bronchitis ___ Coughing ___ Wheezing ___ Coughing up blood ___ Chest stuffiness ___

Coughing up phlegm clear/yellow ___ Pain inhaling ___ Tight chest ____ Difficulty breathing ___

Cardiovascular Chest pain ___ Palpitations ___ Racing heart ___ Irregular heartbeat ___

Anaemia___ Cold hands,feet ___ Swelling/oedema in ankles/feet ___ Varicose veins ___

Gastrointestinal Average number of bowel movements a day? ______Colour ______

Bad breath ___ Nausea ___ Vomiting ___ Burbing ___ Heartburn ___ Acid regurgitation ___

Hiccup ___ Indigestion ___ Abdominal pain ___ Bloating ___ Constipation ___Diarrhoea ___

Loose/soft stools ___ Irregular/infrequent bowel movements ___ Urgency ___ Strong smell ___

Undigested food in stools ___ Blood in stools ___ Mucus in stools ___ Flatulence ___

Rumbling ___ Painful bowel movements ___ Fullness/pain behind ribs ___

Ulcer ___ Hernia ___ Haemorrhoids ___ Prolapsed organs ___ Candidasis ___

Appetite: Always hungry___ Good ___ Poor ___ Hungry but no desire to eat ___Weight loss___

Weight gain ___ Feeling of retention of food instomach ___Sleepiness after meals ___

Skin & Nails Skin: Normal ____ Dry ____ Flaky ____ Oily ____ Bumpy ____ Rashes ___

Easily flushing in face ___ Acne ___ Eczema ___ Psoriasis ___ Rosacea ___Itching ___

Atopic dermatitis ___Easy bruising ___ Sweating easily or spontaneous sweating ___

Sweating on exertion ___ Profuse sweating ___Night sweating ___ Sensation of heat/flushing ___

Fever ___ Chills ___ Aversion to heat ___ Aversion to cold ___ Easily feeling chilled ___

Easily feeling hot ___Soft or brittle nails ___

Genito-urinary Frequent thirst ___ Lack of thirst ___ Desire for hot drinks ___

Desire for cold drinks ___ Frequent urination ___ Scanty urination ___ Urgent urination ___

Colour of urine: Clear ___ Pale yellow ___ Dark yellow ___ Painful urination ___ Dribbling ___

Incontinence ___ Getting up in the night ___ Burning sensation ___ Bloody urine ___

Strong smell ___ Oedema or swelling___ Kidney stones ___Urinary tract infections ___

Male reproductive Pain/itching of genitalia___ Genital discharge ___ Erectile dysfunction ___

Increased libido ___ Decreased libido ___ Impotence ___Premature ejaculation ___

Nocturnal emission ___ Prostate disorder ___ Infertilityor sub fertility___

Female reproductive

Are you or could you be pregnant? Y N Are you breast-feeding? Y N

If you have children, please list number & methods of birth & any problems ______

______

Normal method of contraception ______

Age you first began to menstruate ______

Is your cycle: Regular ___ Irregular ___ Often early ___ Often late ___ Absent ___

How many days do you bleed? ______

Cycle length Normal (25-29 days) Long (30+ days) Short cycle (24- days)

Is your flow? Heavy ___ Light ___ Average ___ Thick ___ Watery ___ Average ___ Clotted ___

Is the colour? Pink/pale ___ Bright red ___ Dark red ___ Brown ___

Do you spot between periods? Y N

Are you periods painful? Y N

Describe the pain & at what point in your cycle you feel it ______

______

Do you get PMS symptoms? Bloating ___ Breast tenderness ___ Cramps ___ Nausea ___ Headaches ___

Low mood ___ Irritability ___ Weepiness ___ Fatigue ___ Acne ___ Sleep disturbance ___

Is your vaginal discharge? White ___ Clear ___ Yellowish ___ Pink ___ Thick ___ Watery ___

Strong smelling ___

Vaginal itching/burning? Y N Frequent yeast infections? Y N Frequent urinary infections? Y N

Do you have? Pain during intercourse ___ Bleeding after intercourse ___ Low libido ___ Hot flushes ___

Vaginal dryness ___ Infertility or sub fertility ___

Age of menopause ______Hysterectomy age & reason ______

______

Have you been diagnosed with? Breast lumps/cysts ___ Endometriosis ___ Chlamydia ___ Fibroids ___

Polyps ___ Polycystic Ovary Syndrome ___ Pelvic Inflammatory Disease ___ Uterine prolapse ___

If you are pregnant, please list any health concerns you would like to have treated: ______

For Your Information— Please read the following and indicate your understanding by signing below:

I hereby request and consent to the one or more of the following being performed on myself (or the client named below, for whom I am legally responsible):

  • TCM and Western diagnostic procedures including questioning, pulse and tongue evaluation, postural assessment, range of motion, muscle and joint testing.
  • Physical therapy including one or more of the following: acupuncture; electro-acupuncture; cupping, moxibustion;Tui-Na; Thai Yoga; Acupressure;Shiatsu;Chi Nei Tsang abdominal massage and Western remedial & myofascial bodywork.
  • Advice on diet, lifestyle, remedial exercise; simple breathwork; stretching & postural alignment and prescription of herbal therapy where appropriate.

The treatment:

  • Only sterile, disposable needles are used throughout your treatment.
  • Occasionally you may get bruising after needling or cupping. Please do not worry about this: the bruise will fade after a few days.
  • Herbal medicines are intended only for the person for whom they areprescribed. Please do not give your herbal prescriptions to anyone else.

The information that I have provided is accurate to my knowledge and understanding. I will also inform the therapist of any changes to my condition or health that may impact my treatment.

Signature…………………………………………………………………………………. Date………………………………….

Signature of therapist……………………………………………………………….. Date………………………………….

Copyright: Tyler Cornelius BSc (Hons) TCM,Bachelor of Medicine (Beijing), MATCM, BTEC (Dip), NLSSM (Dip), MISRM, Dip Oriental Bodywork.