Patient information

Address

If the patient is a minor or incapacitated, who is their legal guardian or representative?

Emergency contact

Address

MAJOR COMPLAINT (by priority)

OTHER COMPLAINTS

by priority

Describe your pain from 0 up to 10 (0 no pain , 10 unbearable)

Other diseases:(problems)

Describe your pain from 0 up to 10 (0 no pain , 10 unbearable)

THINGS TO BRING WITH YOU TO YOUR FIRST APPOINTMENT:
1. "Patient information" form filled out completely.
2. Bring X-rays, laboratory reports, blood tests, doctor's reports etc.
3. Bring (in their original containers) all medications you are currently taking.
4. Bring (in their original containers) all supplements, herbs, etc. you are currently taking.

Nutrition and lifestyles

Medical History

patient symptom survey

The information you provide is strictly confidential.
Please check any condition you Now have Now (N),or have had in the Past (more than 12 months) past(P) Now and Past (N and P).

Family History

Has any member of your family had any of the above conditions?

If yes - Which family member and what did they have?

Accidents, Falls , Broken bones

Have you been in any car accidents, fallen and/or broken bones, or suffered other traumas resulting in injuries? Please list the date and event, starting with the most recent.

Surgeries, Medical Procedures

Please list them, along with the dates, starting with the most recent. Have you been advised to undergo surgical procedures that you have not had?

Medications,Drugs,Herbs or supplements

Please list the Medication by Name / dosage in mg./mcg., etc. / how often (AM-Noon-PM) as 1-0-1, etc. / how long taking (# weeks, or # months, # years, etc.)

Mental, Emotional and neurological

Female Reproductive system

Male reproductive system

Nutrition and lifestyles

Often people have concerns about their health but are too embarrassed or afraid to ask.

Do you have any questions or concerns about:

How do you feel about the following areas of your life?: Please tick the space that applies.

External/skeletal Exam

Head

Eyes

Nose

Ears

Neck/Throat

Shoulders

Arms, elbows, wrists and hands

Please select "R" (right), "L" (left) or "A" (both)

Back

Chest

Hips

Legs and knees

Ankles, feet and toes

Examination of internal organs

Lungs, Heart

Liver and gallbladder

Kidney and urinary bladder

Stomach, digestion and appetite

Small intestine, large intestine and rectum

Skin and sweating

REQUEST FOR ACUPUNCTURE TREATMENT

I understand that treatment methods may include (but are not limited to) acupuncture, electrical stimulation, chiropractic, Tui Na (Chinese massage), Swedish massage, Chinese herbal medicine, and supplements, nutrition and lifestyle advice. This clinic uses sterile, (single use) disposable needles.

I will notify the acupuncturist if I am or become pregnant; if there is any change in my health condition or medications or if I have any adverse reaction to the treatments.

I understand all my records will be kept confidential and will not be disclosed without my written consent.

My intention is to receive and complete the course of treatment for my current condition and for any future condition(s) for which I seek treatment.

You have finished the ?Patient Information? form for Passport To Health. Below please enter your name, your email address, and then select the button where the form is to be sent. To the Clinic