Lifestyles Wellness Spa & Fitness Center



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1180 Stellar Drive, Newmarket, On, L3Y 7B9

Tel: 905-953-8088

CLIENT INTAKE FORM

Today’s Date: _________________________

Name: ____________________________________________________ Date of Birth: _____________________________

Address: _______________________________________________City: ____________________Postal Code: _______________

Telephone: (home) _______________________________________ (Alt) _________________________________________

Email: _______________________________________________How did you hear about us? _____________________________

Emergency Contact Name: ____________________________Relationship: ___________________Tele: ____________________

Employer: _______________________________ Occupation: _____________________________________________________

Welcome to Lifestyles. We emphasize the team approach to wellness, prevention and treatment of disease. Our purpose is to help you achieve and maintain your health-related goals. We work together with you, that means you are invited to participate as actively as possible in the work we do together. We provide many services which are commonly reimbursed by typical insurance companies. Insurers vary in their rules, regarding acupuncture, massage therapy and other modalities. Because of the changing nature of this system, private payment is necessary for our services at the time of your visit. We will provide all necessary documentation to you in order for you to submit a claim for reimbursement to your insurer. We look forward to becoming health partners with you.

I authorize Lifestyles Wellness Spa & Fitness Center Inc. to release information to my insurance company pertaining to my health care in order for them to process a claim which is being submitted for reimbursement.

I am responsible for paying all fees at the time of service

I will provide Lifestyles Wellness Spa & Fitness Center Inc. at least 24 hours notice should I require to cancel an appointment or I will be held responsible for the full service fee

I understand Herbal products and Supplements are not returnable

Acupuncture, herbal medicine, Tuina massage, nutrition and other TCM modalities are safe and effective for the prevention and treatment of a wide range of health problems and for the promotion of general well being. Although TCM is helpful for many health conditions, it is not intended to replace any tests or treatments recommended by your physicians. It is advised that you inform your physician and other practitioners of your choice of various treatment modalities so that a team approach may be employing to treat you. Please note that acupuncture and Tuina massage are safe. Occasional bruising, and post needling sensation may happen. Fainting may occur for new patients due to nervousness, hunger or extreme fatigue. Chinese herbs are also very safe and effective when recommended by qualified practitioners. Occasional abdominal upset or diarrhoea may occur although this can be the response of the body to treatment. If you have any concerns, please do not hesitate to ask.

Client Statement:

I _________________________________ (undersigned patient) herby request and consent to receive treatment from Lifestyles Wellness Spa & Fitness Center Inc. including Traditional Chinese Medical treatments including acupuncture, herbal medicine, medicated diets, Tuina Massage and other related treatments from the practitioners. I acknowledge that the above treatments and all its ramifications have been fully explained to me. I also absolve Lifestyles Wellness Spa & Fitness Center Inc. and all practitioners if I experience any unexpected effects resulting from the treatment. I further agree to not commence lawsuit of any kind against all parties mentioned. This statement is being signed voluntarily.

Client name __________________________________ Signature ______________________________

Parent or guardian name, if under age 18._______________________________________Date _______________

Your Medical History: Please circle all that apply and record year:

Diabetes, High Blood Pressure, Low Blood Pressure, Anaemia, Thyroid, Cancer, HIV, Heart Disease, Intestinal disease, Ulcers, Cholesterol, Seizures, Prostate problems, Arthritis, Infertility, Liver disease, Stroke, Addictions, Bone Density concerns, Severe burns, Neurological or Psychological problems, Contagious disease, Other –please list.

Years Diagnosed: _________________________________________________________________________________________________

Hereditary illness in the family _______________________________________________________________________

Please list any times of hospitalization including any surgery you have and record year: _________________________________________________________________________________________________Please list any medication you are currently taking (prescription or over the counter):

Medication _______________________________ Condition __________________________________Year______

Medication _______________________________ Condition __________________________________ Year______

Medication _______________________________ Condition __________________________________ Year______

Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking:

Supplement _____________________________Dose________ Condition __________________________________

Supplement _____________________________Dose________ Condition __________________________________

Supplement _____________________________Dose________ Condition __________________________________

Health care providers and other treatments –medical or holistic

Name_____________________________Telephone # ____________________ Type of care _____________________

Name_____________________________Telephone # ____________________ Type of care _____________________

Name_____________________________Telephone # ____________________ Type of care _____________________

Please list any allergies: _____________________________________________________________________________

Are you pregnant Yes Due Date:___________________ No Do you Smoke Yes No

What would you eat in a typical day?

Breakfast: ________________________________________________________________________________________

Lunch: ___________________________________________________________________________________________

Dinner: __________________________________________________________________________________________

Snacks: __________________________________________________________________________________________

How many cups: Coffee ____ Tea ____ Soft drink____ Alcohol____ Water____ Juice____ Milk_____ Other:________

Cravings: ________________________________________________________________________________________

Please list any foods you avoid and why: ________________________________________________________________

Are you a: Meat eater Vegetarian Vegan Since_________________ Reason _______________________

How often do you consume meat: ____________ Source/type of meat_________________________________

How often do you consume dairy: ____________ Source/type of dairy________________________________

Please list types of physical activity and frequency:

_________________________________________________________________________________________________

Please take the time to complete the form honestly and in complete detail

What would you most like to achieve through your treatments? _________________________________________________________________________________________________Condition: began, relieving/exasperating factors:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General Information: PLEASE CIRCLE YOUR CURRENT SYMPTOMS

▪ Body Temp: cold/warm hands/feet; feel hot/cold/alter; sensitive to weather change, hot flash, sweat easily

Part of body that sweats or experiences heat: _____________________________________________________________________________________________________

▪ Thirst: increase/decrease, prefer hot/cold fluids, dry mouth

_____________________________________________________________________________________________________

▪ Urine: back pain with urination or holding urine, bladder infections, Kid stones, painful or burning urine, blood delayed weak stream, frequent urine, urgent urine, small/large amount, leak, night urine, smell,

Color of urine: _________________________________________________________________________________________

▪ B.M: diarrhoea/constipation/alter, urgent, burn, itchy, mucous, pain, blood in stool undigested food,

hard to digest fats or raw food, haemorrhoids, bulk: thin, narrow, pellets, parasites, Candida, incomplete empty, Color of stool: ______________________________How many bowel movements each day? _____________________________________________________________________________________________________

▪ Abdomen: nausea/vomit, heartburn, belch, bloat/full, gas, pain/burn/cramp/spasm, increase/decrease appetite, stress aggravates, tired before/after meal, miss meal: confused, irritable, dizzy, poor focus, shaky, clammy

_____________________________________________________________________________________________________

▪ Head: poor memory, faint/dizzy/fuzzy, poor balance/coordination, poor concentration/confused,

headaches/migraines, dull, sharp/stabbing pain, ______________________________________________________

worse: list time of day, weather, food triggers, stiff neck _______________________________________________________

Frequency of headaches____________________________ Location of headaches:__________________________________

▪ Hair: loss, dandruff/dry scalp, oily, brittle, thin, early grey, excess/less growth

_____________________________________________________________________________________________________

▪ Skin: fungal infections, rash, increase pigment, color –yellow, red, pale, sores, acne, poor wound healing, white patches, bruise/bleed easily, dry/itchy, sensitive to sun, bumps on back of arms, poor tone/elasticity

_____________________________________________________________________________________________________

▪ Nails: blue, brittle/thin, pitted, white spots

_____________________________________________________________________________________________________

▪ Body recent weight gain/loss, feel heavy Lymph: water retention -Location: ______________________________swell throat/armpits/groin -Factors: _______________________________

_____________________________________________________________________________________________________

▪ Bones, joints, muscles: TMJ, crack, poor posture, weak, muscle loss, decrease height, swelling,

calcium deposits, poor flexibility, shaky, numb, restless legs, cramp, twitch, aches/stiff/pain, decrease range, better/worse exercise,

List location of symptoms: ________________________________________________________________________________

_____________________________________________________________________________________________________

▪ Lu & Nose: allergies –season___________________, cough –dry or mucous ________________asthma,

frequent colds/flu -# of times past year________________ nosebleed, dry nose, snore, nasal drip,

breath –deep/shallow, Shortness of breath, ill with damp conditions, sinus congestion/infections -# of times past year_________, phlegm –color _____________, noticed when_________________________________________________

_____________________________________________________________________________________________________

▪ Chest: palpitation, pounding, heaviness, tight, shortness of breath, sweating, Breast: swell, lump, tender, produce milk w/o nursing

_____________________________________________________________________________________________________

▪ Ears: wax –Hard or Moist___________ itchy, infection -# of times past year_________________

hearing loss –Right or Left ________ Since ________________________________________________________________

ringing/buzzing –Right or Left ______________________ High pitch, Low pitch, ache –when_______________________

_____________________________________________________________________________________________________

▪ Eye: infection, spots/floaters, dry/burn, strain/pain, heavy, watery, puffy, blurry, sensitive,

color of the whites of the eye: ___________________________________________________________________________

_____________________________________________________________________________________________________

▪ Mouth: dry, hard to chew/open, smell/taste: foul, sweet, bitter, burnt; mouth/tongue sores (cankers)

Tongue: twitch, swollen, tender, Throat: hard to swallow, swollen, sore, dry, Teeth: grind tooth decay, Gums: inflamed, bleeding, Lips: dry, sores, crack, swollen, color of lips: ____________________________

_____________________________________________________________________________________________________

▪ Emotions: depressed, suicidal, anxiety, shy, hyper, aggressive, obsessive, restless, irritable, frightened, stress, overworked, feel stuck, hard to carry out plans

Do you feel fulfilled in your current career? ___________________________________________________________________

Are you in a positive work environment –boss, co-workers, clients? ________________________________________________

How many hours do you work each week? ___________________________________________________________________

Shift work? __________________________ Steady hours? ______________________Financial security_________________

Time to commute to work? ______________________________________________ High traffic?_______________________

Do you have support from friends/family?____________________________________________________________________

How do you handle your emotions? _____________________________________________________________________________________________________

▪ Energy: exhausted, sleepy, sluggish, excess, increase/decrease with stress/exercise/caffeine/eating

_____________________________________________________________________________________________________

▪ Sleep: hard to fall asleep/stay asleep, hard to fall back to sleep, insomnia, wake tired, sleep apnoea

vivid dreams –types of dreams __________________________________________________________________________

How many hours of sleep do you get each night?_____________________ # of times you wake_________________________ Reasons you wake (light sleeper, hot, sweat, thinking, urinate, restless body, aches) _____________________________________________________________________________________________________

▪ Libido: increase/decrease, painful

_____________________________________________________________________________________________________

▪ Male: swelling groin, painful testes, sexual dysfunction: erectile, ejaculation, impotence, cold/numb

_____________________________________________________________________________________________________

Thank you for taking the time to complete the form honestly and in complete detail.

▪ Tongue:___________________________________________________________________________________________

▪ Pulse: ____________________________________________________________________________________________

▪ TCM Diagnosis: _____________________________________________________________________________________________

▪ Treatment:_________________________________________________________________________________________

Female:

Age at which menses began: __________ Date of last menstrual period began ____________________

Are your menstrual cycles regular? Yes No How many days are there from one period to the next? _________

Have your cycles changed since they began? Yes No How____________________________________________

Do your bowel movements become lose at the beginning of your period? Yes No

Are your periods painful? Yes No How long does the pain last? _____________ Medication? ____________________

How many days do you normally bleed? ___________________ How heavy is the bleed? Light Normal Heavy

What color is the blood? Pink Light red Red Dark red Purple Brown Black

Is there clotting: Yes No

Do you ovulate on your own: Yes No

On what day of your cycle ___________ Describe discharge color ___________, smell _________, amount _______________

2 weeks before menses: spotting confused/forgetful headache, location____________________________________ diarrhoea constipation, palpitations, tired anxiety, nervous irritable/anger/resentful depressed/hopeless

nausea, vomiting, weight gain, water retention/bloat, frequent urination, low back pain, breast tenderness,

insomnia, increase sweat, breakouts, abdominal cramping

Number Years

How many pregnancies have you had? ________ _____________________________

How many children do you have? ________ _____________________________

How many abortions have you had? ________ _____________________________

How many miscarriages have you had? ________ _____________________________

How many times has a D&C been performed? _______ _____________________________

Any problems during pregnancy, birthing or postpartum? ________________________________________________________

Date of last Pap smear _______________ Any findings past or present?____________________________________________

Have you ever had a cervical biopsy, operation, cauterization or conization? Yes No

Have you ever had a venereal disease? Yes No

Do you get yeast infections regularly? Yes No Medication?______________________________________________

Have you ever been diagnosed with a chlamydial infection? Yes No

Do you have chronic vaginal discharge? Yes No

Do you have any sores on your genitalia? Yes No

Have you ever had pelvic inflammatory disease? Yes No How was it treated?______________________________

Have you ever been diagnosed with: uterine fibroids Yes No polyps Yes No endometriosis Yes No pelvic adhesions Yes No pelvic abnormalities Yes No

Have you ever taken any medications for gynaecological conditions other than contraceptives?

Medication _______________________________ Condition __________________________________Year______

Medication _______________________________ Condition __________________________________ Year______

Have you had fertility treatments? Yes No Type & When _____________________________________________

Where ___________________________________________________

Have you taken medication to help you ovulate? Yes No When_________________ How long? ____________

Have your fallopian tubes been evaluated medically? Yes No Results__________________________________

Have you had tubal operations? Yes No

Have you had any hormone laboratory test performed? Yes No Results________________________________

Have you taken oral contraceptives? Yes No When__________________________________________________

Have you ever had an IUD? Yes No When__________________________________________________

Have you ever taken DepoProvera? Yes No When__________________________________________________

How is your sexual energy? Low Normal High

Do you douche? Yes No With what ______________________________________________________________

Do you use vaginal lubricants? Yes No Are you presently taking steroids? Yes No

Are you 20% over you ideal body weight? Yes No Are you 20% below you ideal body weight? Yes No

Do you have excessive facial hair? Yes No Do you have excessively oily skin? Yes No

Any excessive loss of head hair? Yes No Any discharge from your nipples? Yes No

Was your mother exposed to any environmental toxins / hormones when she was pregnant with you? Yes No

Have you been exposed to any known environmental toxins or hormones? Yes No

Have you had a diagnosis relation to infertility? Yes No What_________________________________________

How long have you been trying to conceive? _____________Is your partner supportive of your with to conceive? Yes No

Menopause: date: ___________ Mammogram: date ___________ Results? ____________________________________

Today is day ______________________ in my cycle.

Thank you for taking the time to complete the form honestly and in complete detail.

▪ Tongue:___________________________________________________________________________________________

▪ Pulse: ____________________________________________________________________________________________

▪ TCM Diagnosis: _____________________________________________________________________________________________

▪ Treatment:_________________________________________________________________________________________

Patient Name: ______________________________________ Age: _________ Date: ________________________

Summery: 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