Preston Merrell Health
306 – 8047 199 Street,Langley, BC V2Y 0E2
Phone: 604.371.3738 Fax: 604.371.3300
Dr. Kevin Preston (DTCM) & Todd Merrell
Name: ______Date: ______
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Circle: Miss. Ms. Mrs. Mr. Birth Date: (DD/ MM/ YYYY)______Age: ______
Address: ______City: ______
Province/State: ______Country:______Postal Code/Zip: ______
Email: ______Phone: ______
Occupation: ______
Family Doctor: ______Phone: ______
Emergency Contact: ______Phone: ______
Primary reason for visit: ______
Other areas of concern: ______
MedicalHistory: List any serious illness, hospitalizations, injuries, accidents, or surgeries.
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Current medication(s): ______
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Are you currently seeing any other practitioners? Circle:
Massage Chiropractic Naturopath Physio TCM Other: ______
Do you have any allergies? ______
Please indicate below with a ‘C’ (current) or ‘P’ (past) if applicable:
___Anxiety ___Headaches
___Arthritis___Heart Condition
___Cancer___Hepatitis (any type)
___Contagious illness ___High Blood Pressure
___Deep Vein Thrombosis (DVT)___History of dizziness or fainting
___Depression___HIV/AIDS
___Diabetes (Metabolic Syndromes)___Insomnia/Sleep issues
___Digestive Issues/Gastrointestinal___Kidney Disorder
___Epilepsy or similar condition___Low Blood Pressure
___Haemophiliac/Bleeding Disorders___Migraines
___Neurological condition/disorder___Skin issue (Eczema, psoriasis)
___Osteoarthritis___Spinal injury
___Osteoporosis___Sleep apnea
___Pacemaker (How long?) ___Sprain/Strain
___Pregnant or possibility of pregnancy___Stroke (Including TIA’s, etc.)
___Respiratory condition (Asthma, etc.)___Upcoming surgery
Please list supplements/vitamins, herbals, homeopathics you are taking currently:
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Please rate your overall health well-being (circle): 1 is poor…10 is excellent
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Please rate your overall sleep quality (circle):
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Please rate your overall energy level (circle):
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On a scale of 1-10 with 10 being very high…please rate your overall stress level (circle):
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Do you use the following? How often? Cigarettes______Alcohol______Drugs______
Do you participate in any physical activity/exercise?______
Family medical history: (Please list any known conditions or causes of death)______
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Preston Merrell Health
306 – 8047 199 Street, Langley, BC V2Y0E2
Fee Policy: In consideration of your fellow patients and your practitioner, please allow a minimum of 24 HOURS NOTICE to change or cancel your appointment. You are responsible for missed appointments or late cancellations and will be charged full fees subject to the practitioner’s discretion.
I understand the Fee Policy. Initial: ______
Informed consent for any and all Treatment, Procedures, & Tests with Preston Merrell Health
I agree and consent to the performance of Traditional Chinese Medicine and biological medical procedures, treatments, or assessments. I understand that such procedures may include, but are not limited to; Meridian Stress Assessment (MSA)/Electro Dermal Screening (EDS), acupuncture, moxibustion, cupping & gua-sha (dermal friction technique), infrared heat lamp, stretching, exercise therapy, Tui-Na (Chinese massage), ear seeds, Chinese or western herbal medicine, homeopathics, homotoxicology, nutraceuticals, supplements, and nutritional counseling & advice.
I understand that I can ask questions at any time and may discontinue or decline any specific therapies at my own discretion.
The herbal and/or homeopathic suggestions and treatments provided by Preston Merrell Health are not intended to replace conventional or primary care. MSA/EDS does not constitute a medical diagnosis, prescription, or treatment nor are the specific protocols intended to treat or prevent illness or disease. MSA/EDS is performed for the sole purpose of aiding the practitioners in the design of an herbal and/or homeopathic protocol, which is intended to balance meridians/channels in accordance with Traditional Chinese Medicine. I agree that I will take the prescribed treatments described herein at my own risk. I do not expect the practitioners of the clinic to be able to anticipate and explain all possible risks and complications of taking the prescribed medications or treatments.
The information received and collected about our patients from their visit to the clinic is strictly private and confidential. It is used and viewed only by the practitioners and staff employed by Preston Merrell Health and will not be released without my written consent.
In all acupuncture treatments only sterile, single use, disposable stainless steel needles are used. Acupuncture may have some side effects including bruising, numbness or tingling, dizziness or fainting, minor swelling or bleeding. I will notify the practitioner if I experience any symptoms or issues related to treatments.
In addition, the herbal and/or homeopathic product suggestions or prescriptions provided may produce side effects that include but are not limited to fatigue, drowsiness, recurrence of previous symptoms and allergic reaction.
Print name in full: ______
Signature: ______
Signature of client or of parent/guardian if under 18
Date: ______