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Template for Medical Acupuncture ConsentPlease ensure you complete all?the fields. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.Personal InformationFull Name:_________________________________________Resident of:_________________________________________ _________________________________________Birth Date:_________________________________________E-mail:_________________________________________Contact:_________________________________________Occupation_________________________________________ Emergency Contact_________________________________________Allergies, if any:_________________________________________ _________________________________________Medications, if any taken or taking_________________________________________ _________________________________________Have you ever had Acupuncture before?_________________________________________If yes, was the treatment effective?_________________________________________The following questions relate to your current and previous health condition. All information will be kept hidden and maintained confidentially. No information will be disclosed or shared without your?written consent.?Have you ever been diagnosed with any of the following?AsthmaDiabetesCancerHepatitisEpilepsyHIV/AIDsTuberculosisMultiple SclerosisPolioLeukemiaSARS/BirdsFLUHeart DiseaseHigh Blood PressureHigh CholesterolDepressionAnxietyPTSDIBSAutoimmune DiseasePlease complete the following questionnaire to the best of your knowledge.Past operations, injuries & health history, if any.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Major Ailment_________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe the beginning of the Major Ailment._________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe the medical tests you had for its treatment and its result? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Frequency of pain or discomfort. Please select the most accurateConstantOff/OnAt restWith activityAt what time of day is the pain or discomfort at its worse?MorningAfternoonEveningSleep Have you ever injured with this area before?______________________________________________________________________________________________________________________________________________________Have you ever been in any accident (automobile, work, falls, etc.)?______________________________________________________________________________________________________________________________________________________List all related treatments received for this condition.______________________________________________________________________________________________________________________________________________________Have you ever received acupuncture for a specific problem or injury?______________________________________________________________________________________________________________________________________________________Is there anything that you do that increases or decreases discomfort or pain?______________________________________________________________________________________________________________________________________________________What are the physical duties required of your occupation?______________________________________________________________________________________________________________________________________________________ What activities/hobbies do you enjoy?______________________________________________________________________________________________________________________________________________________How many children do you have?___________________________________________________________________________Please list any exercise or relaxation/stress reduction activities you do (including frequency).______________________________________________________________________________________________________________________________________________________Please indicate if you see any other healthcare practitioners from the list below?ChiropractorNaturopathOsteopathKinesiologistPhysiotherapistsExercise PhysiologistOther ___________________________ReikiNutritionistFeldenkraisMassage TherapistGPEnergy Balancing TherapistPilatesWho is your General Doctor?______________________________________________________________________________________________________________________________________________________Please check any symptoms that apply to you or mention if there’s any other.Digestion & BowelsBloatingPain or discomfortPain above navelPain below navelLower abdomenRight side abdomenLeft side abdomenCramping painConstipationAcid tasteSour tasteBitter tasteSugar cravingsPain relieved with passing windOther ___________________________Breathing & SinusDifficulty in breathingShort of breathAsthmaCoughThroat irritationRinging in earsDifficulty in swallowingPhlegmBlocked feeling in throatAllergiesNasal dischargePost nasal dripBlocked noseNose surgeryNose injuryOther ___________________________Heart and Blood vessel CirculationHigh blood pressureLow blood pressurePain in chestDizzinessStrokeDVTSurgeryDiagnosed heart diseaseBlocked arteriesVaricose veinsNumbnessPins and needlesOther ___________________________UrinationIncontinencePain while passing urineUrgency with painUrgency without painLong streamShort streamProstrate conditionKidney diseaseCystitisBurning sensationDark yellow colorOrange colorPale straw colorMore than 5 times during dayMore than once during nightDiagnosed UTIOther ___________________________Skin, Hair, Nails & DentalDry skinRashesCracked skin on fingersAcneCracked nailsRidges on nailsToothacheTooth nerve painDandruffDermatitisAlopeciaPsoriasisEczemaFungal infectionGingivitisGum infectionOther ___________________________MenstruationIrregular periodsHeavy periodsPain or crampingAmenorrheaDysmenorrhealCongealed bloodHormone testsPain medicationHeadacheBack painLaparoscopyAnxietyDepressionSpottingChange bowelsNauseaEndometriosisD&CPCOSUsing IUD or contraceptive pillsOther ___________________________At what age did you have your first period?________________________For how many days is your period cycle? ________________________What is the color of discharge at the start of your period?________________________HeadHeadachesTension in templatesDizzinessRinging in earsFaintingSinus congestion/Nasal dischargeLight headednessAround eyesRed eyesIrritated eyesWeepy eyesOther ___________________________NeckDisc herniationPain at the base of the neckPain when moving side to sidePain when turningNeck feels out of placeBone spursMuscle spasm in neckStiffnessTMJ disorderArthritisWhiplashOther __________________________ShouldersPain in shoulder – front/back/topPain with activityPain at restsPain wakes from sleepsPain in morning while walkingBursitisArthritisShoulder surgeryCan’t raise arm above shoulderOther ___________________________Arms and HandsPain in upper armPain in forearmPain in wristPain in fingersFingers go to sleepSore joints in fingersSwollen jointsSensation of pins and needlesDiagnosed arthritisLoss of grip strengthHands coldSensation referred down arm to handOther ___________________________Mid-BackMid-back painPain with breathingPain between shoulder bladesPain up/down backRestricted movementPain along spinePain around entire torsoTight along sides of torsoOther ___________________________Low BackLow back painPain in worse workingPain in worse liftingPain in worse standingPain in worse sittingPain in worse bendingPain in worse coughingPinched nerveDisc herniationLow back feels out of placeArthritisSurgeryOther ___________________________Legs and FeetPain down in right legPain down in left legLeg crampsSweaty feetSwollen footCramps in footCold feelingDiagnosed arthritisPain in right kneePain in left kneeKnee surgeryNumbness in lossPin & needlesInjuryOther ___________________________HipPain in buttocksPain in side of hipPain in hip jointPain in side of a legPain in back of a legPain in sir boneDiagnosed bursitisDiagnosed arthritisSurgeryInjuryOther ___________________________I, _______________, solemnly declare that particulars given above are true correct to my best knowledge and belief._________________________ (Patient’s name and signature)Please sign your initials after reading the T&C on the very next page, that you have received and understand our policy.Medical Acupuncture Consent Form(Clinic’s name)“ACUPUNCTURE” means the stimulation of a certain point or points near the surface of the body by installation of thin needles. Medical acupuncture involves insertion of fine, solid stainless steel needles into the skin at specific points on the body to achieve a therapeutic effect. It also often serves in the treatment of certain diseases or dysfunctions of the body.Acupuncture may allow the painless relief of one’s symptoms without the need for drugs, and improve balance of bodily energies leading to the prevention of illness, or the elimination of the presenting problems.You should also know about the risks involved: Although acupuncture is generally safe and serious problems are rare. But there may be some risks. Needles which are not sterile can cause infection. Make sure that your practitioner uses sterile needles which are thrown away after one use. Here, it should bring to your knowledge that we only use new, disposable sterile needles, so infection is rare.?In some acupuncture points, needles inserted too deeply which can puncture the lungs or gallbladder or cause problems with your blood vessels. That is why it is important to use a practitioner who is well-trained in acupuncture.Herbal Remedies: The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify my practitioner if I experience any of the above-mentioned side effects or if I become pregnant.I have read the above, understand the risks involved, and consent to medical acupuncture treatment. By voluntarily signing below, I show that I have read the above and give my consent for the treatment.I accept full responsibility for payment of all treatment fees. Patient’s name__________________Patient’s signature__________________Dated__________________ ................
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