Barrie Vaughan Woodbridge Traditional Chinese Medicine



Application for TreatmentPersonal Information DateNameInsurance FORMCHECKBOX Y FORMCHECKBOX NFirstMiddleLastGender FORMCHECKBOX Male FORMCHECKBOX FemaleAddressPostal CodeDate of BirthyymmddOccupationPhoneHomeCellWorkEmailEmergency ContactChief ComplaintThe reason why you seek for Traditional Chinese Medicine.Current MedicationPlease write here all medications that you are currently taking. Or let us have a photocopy of the list of medications you are currently taking.PhysicianContact NumberPurpose of Visit FORMCHECKBOX Consultation only FORMCHECKBOX Consultation with TreatmentTreatment Modalities FORMCHECKBOX Acupuncture FORMCHECKBOX Herbal Medicine FORMCHECKBOX Tuina Massage FORMCHECKBOX OtherOtherPlease describe here other modalities such as moxibustion, cupping, Guasha, etc.Past Traditional Chinese Medicine HistoryHave you ever been treated with Traditional Chinese Medicine? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please check any treatments you have received. FORMCHECKBOX Acupuncture FORMCHECKBOX Herbal Medicine FORMCHECKBOX Tuina Massage FORMCHECKBOX Moxibustion FORMCHECKBOX Cupping FORMCHECKBOX OtherMedical HistoryYour Past Medical History:Family Medical History: FORMCHECKBOX AIDS FORMCHECKBOX HIV FORMCHECKBOX HVB (Hepatitis B) FORMCHECKBOX Cancer FORMCHECKBOX Diabetes FORMCHECKBOX High Blood Pressure FORMCHECKBOX Heart Disease, Stroke FORMCHECKBOX Allergies FORMCHECKBOX Alcoholic FORMCHECKBOX Arthritis FORMCHECKBOX Seizures FORMCHECKBOX Thyroid Disease FORMCHECKBOX Surgeries FORMCHECKBOX Venereal Disease FORMCHECKBOX Significant Trauma (auto accident, falls etc.) FORMCHECKBOX Childhood Illness FORMCHECKBOX None FORMCHECKBOX Other: FORMCHECKBOX Cancer (Mother/Father/Other) FORMCHECKBOX Diabetes (Mother/Father/Other) FORMCHECKBOX High Blood Pressure (Mother/Father/Other) FORMCHECKBOX Heart Disease, Stroke (Mother/Father/Other) FORMCHECKBOX Allergies (Mother/Father/Other) FORMCHECKBOX Arthritis (Mother/Father/Other) FORMCHECKBOX Seizures (Mother/Father/Other) FORMCHECKBOX None FORMCHECKBOX Other:Additional description of the above illness or allergies (Please write below)Informed Consent for Traditional Chinese Medicine Treatment and Electronic TransmissionI hereby request and consent to receive Traditional Chinese Medicine (mentioned as TCM hereinafter) treatments including acupuncture, herbal medicine, Tuina massage, and other related modalities within the scope of practice of TCM practitioners and Acupuncturists performed in Mai Medical Health Centre.I understand that, as with all health care, while rare, there may be some risks to treatment, including;With acupuncture:Occasional bruising, post-needling sensation, fainting, miner bleeding, blistering, nausea, infection and shock.Possible reasons for these symptoms are nervousness, hunger, extreme tiredness, muscle tension, or moving of the body after needlingWith herbal medicine:Risk of reactions to treatment including nausea, vomiting, dizziness, headaches, malaise or general worsening of symptomsUnknown interactions between western medications and Chinese herbal medicinesOther modalities (Cupping Therapy):Risks relevant to treatment such as bruising or bleeding and painI also understand that transitions in healing (known as healing crisis) may also produce temporary periods of discomforts including emotional upset, fatigue, malaise, headaches, dizziness, rashes or breakouts, nausea, vomiting or general worsening of symptoms. TCM treatments in general are safe and effective for the prevention and treatment of a wide range of health conditions and for the promotion of general well-being. However, it is not intended to replace tests or treatments recommended by your physicians. I acknowledge that the above treatments and all their ramifications have been fully explained to me and I do not expect the practitioners to be able to anticipate and explain all possible risks and complications. I also absolve the clinic and its practitioners if I experience from any unexpected results of the treatment. I further agree to not commence lawsuit of any kind against all parties mentioned.I hereby assigned benefits payable to the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. I authorize my health care provider to collect, use and disclosure personal information concerning any claims submitted on my behalf. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.Name of the Patient/GuardianSignatureDate: YY/MM/DDCancellation PolicyThe clinic requires 24 hours notice when cancelling an appointment. Please be aware that a fee of $50 will be applied for late cancellation or missed appointment.Cancellation AgreementI understand that I am responsible for payment in full for appointments that are missed without 24 hours notice (1 business day).I have read and agree to the above policy.Name of the Patient/GuardianSignatureDate: YY/MM/DDGeneral Health InformationTo assist us in providing you with the best possible care, please fill out the following questionnaire accurately and thoroughly. Your answers will be kept totally confidential. General information on your health conditionChills/Fever FORMCHECKBOX general chills ( FORMCHECKBOX mild FORMCHECKBOX severe) FORMCHECKBOX aversion to cold FORMCHECKBOX cold limbs FORMCHECKBOX cold lower back FORMCHECKBOX cold abdomen FORMCHECKBOX tidal fever FORMCHECKBOX night fever FORMCHECKBOX afternoon fever FORMCHECKBOX mild fever FORMCHECKBOX high fever FORMCHECKBOX tidal fever FORMCHECKBOX hot flashes FORMCHECKBOX aversion to heat FORMCHECKBOX aversion to wind FORMCHECKBOX heat in the palms, soles and chest FORMCHECKBOX alternating chills and fever FORMCHECKBOX easily catch cold FORMCHECKBOX no chills or feverSweating FORMCHECKBOX no sweating FORMCHECKBOX profuse sweating FORMCHECKBOX night sweating FORMCHECKBOX spontaneous sweating FORMCHECKBOX exhaustion sweating FORMCHECKBOX sweating on the palms, feet and chest FORMCHECKBOX normal Sleep FORMCHECKBOX normal FORMCHECKBOX easily fall asleep FORMCHECKBOX insomnia FORMCHECKBOX easy to wake up and difficult to fall asleep again FORMCHECKBOX easy to wake up but easy to fall asleep again FORMCHECKBOX shallow sleep with easily awakened FORMCHECKBOX difficult to fall asleep when alone due to fear FORMCHECKBOX dream disturbed sleep FORMCHECKBOX excessive dreams FORMCHECKBOX sleep walking FORMCHECKBOX sleep talking FORMCHECKBOX nightmares FORMCHECKBOX seeing ghost FORMCHECKBOX wake up to urinate FORMCHECKBOX heavy feeling upon waking FORMCHECKBOX somnolence (sleepiness during the day) FORMCHECKBOX other: Sleeping Hours:____ / dayHead FORMCHECKBOX vertigo FORMCHECKBOX dizziness FORMCHECKBOX edema or swelling FORMCHECKBOX poor memory FORMCHECKBOX heaviness FORMCHECKBOX fainting FORMCHECKBOX normalHeadache Location FORMCHECKBOX frontal FORMCHECKBOX occipital FORMCHECKBOX vertex FORMCHECKBOX both sides FORMCHECKBOX sinusitis FORMCHECKBOX no headacheQuality FORMCHECKBOX dull FORMCHECKBOX sharp FORMCHECKBOX moving FORMCHECKBOX stabbing FORMCHECKBOX fixed FORMCHECKBOX burning FORMCHECKBOX oppressing FORMCHECKBOX heavyEyes FORMCHECKBOX red eyes FORMCHECKBOX dry eyes FORMCHECKBOX bulging eyes FORMCHECKBOX blurred vision FORMCHECKBOX short-sightedness FORMCHECKBOX night blindness FORMCHECKBOX floaters FORMCHECKBOX tearing FORMCHECKBOX photophobia FORMCHECKBOX pain FORMCHECKBOX itching on eyelids FORMCHECKBOX swelling FORMCHECKBOX normalEars FORMCHECKBOX ringing in the ears FORMCHECKBOX tinnitus FORMCHECKBOX deafness FORMCHECKBOX diminished hearing FORMCHECKBOX normalNose FORMCHECKBOX nasal discharge ( FORMCHECKBOX clear white FORMCHECKBOX yellow sticky) FORMCHECKBOX nasal congestion FORMCHECKBOX rhinitis FORMCHECKBOX flaring sensation FORMCHECKBOX sneezing FORMCHECKBOX normalMouth/Lips FORMCHECKBOX dry mouth FORMCHECKBOX dry lips FORMCHECKBOX ulcers FORMCHECKBOX normalThroat FORMCHECKBOX dry throat FORMCHECKBOX sore throat FORMCHECKBOX difficult to swallow FORMCHECKBOX frequent clearing FORMCHECKBOX feel something in the throat FORMCHECKBOX normalThirst FORMCHECKBOX no thirst FORMCHECKBOX thirst with desire to drink ( FORMCHECKBOX warm drink FORMCHECKBOX cold drink) FORMCHECKBOX thirst without desire to drinkAppetite FORMCHECKBOX poor FORMCHECKBOX excessive FORMCHECKBOX reduced recently FORMCHECKBOX increased recently FORMCHECKBOX no hunger FORMCHECKBOX hunger without desire to eat FORMCHECKBOX hunger even after overeating FORMCHECKBOX normalDiet FORMCHECKBOX irregular FORMCHECKBOX regular FORMCHECKBOX vegetarianCrave for: FORMCHECKBOX spicy FORMCHECKBOX sweet FORMCHECKBOX greasy FORMCHECKBOX salty FORMCHECKBOX raw FORMCHECKBOX noneDigestion FORMCHECKBOX nausea FORMCHECKBOX vomiting FORMCHECKBOX hiccup FORMCHECKBOX belching FORMCHECKBOX vomiting after eating FORMCHECKBOX acid regurgitation FORMCHECKBOX gas FORMCHECKBOX normal FORMCHECKBOX other: Taste Taste in the mouth: FORMCHECKBOX none FORMCHECKBOX bitter FORMCHECKBOX sweet FORMCHECKBOX sour FORMCHECKBOX salty FORMCHECKBOX pungent FORMCHECKBOX sticky sensation FORMCHECKBOX lack of tasteChest FORMCHECKBOX pain FORMCHECKBOX oppression FORMCHECKBOX palpitations FORMCHECKBOX fullness FORMCHECKBOX shortness of breath FORMCHECKBOX wheezing FORMCHECKBOX sighing FORMCHECKBOX cough with( FORMCHECKBOX no sputum FORMCHECKBOX sputum difficult to expectorate FORMCHECKBOX sputum easy to expectorate FORMCHECKBOX blood-streaked sputum FORMCHECKBOX chest pain radiating to left shoulder, back and arm FORMCHECKBOX other: Abdomen FORMCHECKBOX pain worse on pressure or warmth FORMCHECKBOX pain alleviated by pressure or warmth FORMCHECKBOX fullness FORMCHECKBOX distention FORMCHECKBOX pain, distention or fullness on the lateral costal region (rib-side or below rib-side) FORMCHECKBOX borborygmus FORMCHECKBOX gas with flatus (farting) Back FORMCHECKBOX upper back pain FORMCHECKBOX lower back pain FORMCHECKBOX soreness FORMCHECKBOX coldness FORMCHECKBOX other:Limbs FORMCHECKBOX coldness FORMCHECKBOX numbness FORMCHECKBOX tingling FORMCHECKBOX spasm FORMCHECKBOX pain FORMCHECKBOX edema FORMCHECKBOX joint pain (see below) FORMCHECKBOX tremorJoint pain FORMCHECKBOX knee joint FORMCHECKBOX elbow joint FORMCHECKBOX moving pain FORMCHECKBOX fixed pain with heavy sensation FORMCHECKBOX hot, burning pain FORMCHECKBOX pain alleviated by warmth FORMCHECKBOX due to injury FORMCHECKBOX other: Skin FORMCHECKBOX itchy FORMCHECKBOX dry FORMCHECKBOX moist FORMCHECKBOX edema FORMCHECKBOX rashes FORMCHECKBOX carbuncles FORMCHECKBOX allergic FORMCHECKBOX brittle nails FORMCHECKBOX other: Urination and Bowel MovementsUrinationQuality FORMCHECKBOX frequent urination FORMCHECKBOX hesitant urination FORMCHECKBOX difficult to urinate FORMCHECKBOX dribbling FORMCHECKBOX incontinence FORMCHECKBOX urgent urination FORMCHECKBOX burning sensation on urination FORMCHECKBOX painful urination FORMCHECKBOX enuresis FORMCHECKBOX bloody urination FORMCHECKBOX stone FORMCHECKBOX urinary blockage FORMCHECKBOX normalAmount FORMCHECKBOX scanty FORMCHECKBOX copious FORMCHECKBOX normalFrequency_______ times / dayColor FORMCHECKBOX clear FORMCHECKBOX dark yellow FORMCHECKBOX milky FORMCHECKBOX turbid FORMCHECKBOX normal yellowDefecation&Bowel MovementGeneral FORMCHECKBOX constipation FORMCHECKBOX diarrhea ( FORMCHECKBOX watery FORMCHECKBOX foul-smelling FORMCHECKBOX dawn) FORMCHECKBOX dysentery FORMCHECKBOX alternating constipation and diarrhea FORMCHECKBOX normalQuality FORMCHECKBOX dry stools FORMCHECKBOX hard stools FORMCHECKBOX loose stools FORMCHECKBOX undigested food in the stools FORMCHECKBOX stools with mucus FORMCHECKBOX stools with pus FORMCHECKBOX bloody stools FORMCHECKBOX foul-smelling FORMCHECKBOX normalShape FORMCHECKBOX well formed FORMCHECKBOX shapeless FORMCHECKBOX thin stools FORMCHECKBOX unsmooth FORMCHECKBOX pencil-like stools FORMCHECKBOX hard initial stools followed by loose stoolsCondition FORMCHECKBOX urgent defecation FORMCHECKBOX tenesmus FORMCHECKBOX fecal incontinence FORMCHECKBOX difficult but successfully pass out FORMCHECKBOX try to pass out with no result FORMCHECKBOX burning sensation around the anusColor FORMCHECKBOX normal yellow FORMCHECKBOX dark yellow FORMCHECKBOX black tar-like FORMCHECKBOX grayish white FORMCHECKBOX other: Frequency_____ times / day or _____ times / weekEmotions and StressFatigue FORMCHECKBOX fatigued FORMCHECKBOX sleepiness FORMCHECKBOX heavy head and limbs FORMCHECKBOX lassitude FORMCHECKBOX fatigue with desire to lie downEmotion FORMCHECKBOX normal FORMCHECKBOX irritable FORMCHECKBOX anxious FORMCHECKBOX depressed FORMCHECKBOX fearful FORMCHECKBOX restless FORMCHECKBOX prone to anger FORMCHECKBOX mood swinging FORMCHECKBOX manic tendencies FORMCHECKBOX easy to cry FORMCHECKBOX over-thinking FORMCHECKBOX nervousStressCausesLevel/10EnergyFeelingLevel/10Female ConditionMenstruationMenarche AgeDate of last periodDuration (flow)IntervalsAmountClotsColorContraception FORMCHECKBOX Y FORMCHECKBOX NMenopause FORMCHECKBOX Y FORMCHECKBOX NPMSOther discomfortPregnancy FORMCHECKBOX Yes FORMCHECKBOX NoChild BirthLeucorrheaColorSmellAmountMale Condition FORMCHECKBOX normal FORMCHECKBOX seminal emission FORMCHECKBOX impotence FORMCHECKBOX unable to erect FORMCHECKBOX premature ejaculation FORMCHECKBOX nocturnal emission FORMCHECKBOX nocturnal emission with dream FORMCHECKBOX no sexual desire FORMCHECKBOX excessive sexual desire FORMCHECKBOX prostatic hypertrophy FORMCHECKBOX other: Life Style FORMCHECKBOX on diet FORMCHECKBOX exercise ( times/week:__________________) FORMCHECKBOX smoking ( cigarettes/day) FORMCHECKBOX drug FORMCHECKBOX meditation FORMCHECKBOX yoga FORMCHECKBOX alcoholic drinking ( FORMCHECKBOX slight FORMCHECKBOX heavy) Frequency of drinking ( times/week) FORMCHECKBOX other:Other helpful information for your treatmentThank you for your cooperation! ................
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