PatientInformation|HealthHistory|ConsentandRORTraditionalChineseMedicine–Acupuncture–HerbalMedicine

489CollegeStreet,Suite301Toronto,ONM6G1A5

4163248888

Date:___________________ Name:________________________________________________

Preferredpronoun:He/SheDateofBirth:(DD/MM/YR)Age:_____

Address:____________________________________________________________ Postalcode:_______________

Phone(h):____________________(c):____________________ E-mail:______________________________________

Occupation:_______________________________________________________

NameofDoctor/Specialist:_________________________________ Phone:____________________

NameofotherHealthPractitioners:_________________________________________

Emergencycontact:_________________________________________ Phone:____________________

Referredby:______________________________________________________

Fromtimetotimewesendoutanelectronicnewsletterwithourupcomingworkshops,eventsandtalks,healthfulideas,recipesandinspirations.Areyouinterestedinreceivingthis?___________

Pleasenoteyoumayunsubscribetothenewsletteratanytime.

Whatisthemainconditionforwhichyouareseekingtreatment?____________________________________________________________________________________________________________________________________

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Whatisthehistoryofthiscondition(ie.whendiditstart,whatmakesitworse/better?whathaveyoualreadytriedfortreatment?)____________________________________________________________________________________________________________________________________

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PreviousMedicalHistory:Listanypreviousillnessesincludingchildhoodillnessorchronicviralinfections,anysurgeries,traumasoraccidents,evenifunrelatedtoyourcurrentcondition.____________________________________________________________________________________________________________________________________

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Arethereanyconditionsthataresignificantinyourfamily’smedicalhistory?(eg.heartdisease,cancer,stroke,highbloodpressure,kidneydisease,diabetes,asthma,ulcers,mental/emotionaldisorders,etc)____________________________________________________________________________________________________________________________________

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Pleaselistanyallergiesandthereactionyouhave:____________________________________________________________________________________________________________________________________

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Pleaselistanymedicationsorsupplementsyouarecurrentlytaking:____________________________________________________________________________________________________________________________________

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PatientInformation|HealthHistory|ConsentandRORTraditionalChineseMedicine–Acupuncture–HerbalMedicine

DentalHistory:Listanypreviousdentalsurgeries:____________________________________________________________________________________________________________________________________Numberofamalgamfillings,ifany?___________

Lifestyle:Diet–Listwhatyoumighteatonatypicalday:____________________________________________________________________________________________________________________________________

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Howisyourappetite?_______________________ Howoftendoyouhaveabowelmovement?_____________________

Whatmedicationsorsupplementsareyoucurrentlytakingandforwhatreason?____________________________________________________________________________________________________________________________________

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Doyoudrinkcoffee?________Ifso,howmanycupsperday?__________Doyoudrinkalcohol?________Ifso,howmuchandhowoften?__________Doyousmoke?__________Ifso,howmanycigarettesperday?__________Doyouuserecreationaldrugs?__________Ifso,howoften?___________Howmanycupsofwaterdoyoudrinkinaday?___________

Exercise–Whatisyourtypicalactivityinaday?____________________________________________________________________________________________________________________________________

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Areyouonaregularexerciseprogram?(Typeofactivityandfrequency)____________________________________________________________________________________________________________________________________

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Relaxation–Whatisyourlevelofpersonalandoccupationrelatedstress?_________________________________________________________________________________________________________________________Whenyouareunderstress,whatisyourmostcommonemotionalresponse?(Pleasecheckallthatapply) ☐sadness ☐anger ☐worry

☐depression ☐fear ☐anxietyWhatdoyoudoforrelaxation?Howoftendoyouactivelyrelax?____________________________________________________________________________________________________________________________________

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Howmanyhoursofsleepdoyougeteachnight?________________________Doyoufeelrestedwhenyouwakeup?________________________________Doyouworkatacomputer?______Doyouuseacellphone?_________

Whatareyourexpectationsfromourworktogether?____________________________________________________________________________________________________________________________________

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PatientInformation|HealthHistory|ConsentandRORTraditionalChineseMedicine–Acupuncture–HerbalMedicine

Markcurrentsymptoms“C” Markpastsymptoms“P”General___Fatigue___Insomnia___Disturbedsleep___Frequentdreams___Excessivesleep___Dislikecold___Dislikeheat___Weightloss___Weightgain___Fever___Chills___Nightsweats___Daytimesweating___Usuallythirsty___Seldomthirsty___EdemaorswellingOther__________

Skin___Rashes___Hives___Dryskin___Acne___Bruiseeasily___Changesinmoles___UnusualbleedingOther__________

HeadandNeck___Headaches

(locationandtypeofpain)___Dizziness___JawpainOther_________

EyesandEars___Failingvision___Blurredvision___Visualspots___Nightblindness___Eyepainorredness___Ringingintheears___Decreasedhearing___Earpain/dischargeOther___________

Nose,ThroatandMouth___Nosebleeds___Nasaldischarge/infection___Frequentsneezing

___Sorethroat___Hoarseness___Difficultswallowing___Toothorgumpain___Bleedinggums___MouthulcersOther____________

MusclesandJoints___Pain,weaknessornumbnessin:___Neck/shoulder/arm___Hips/leg/feet___Lowback&knees___Musclecramps___Bodypain___Heavylimbs___Swollenjoints___Hotjoints

NervousSystem___Fainting___Paralysis___Tremors___Poorbalance___SeizuresOther___________

Heart,Lungs&Chest___Palpitations___Chestpain___Chesttightness___Rapidheartbeat___Irregularheartbeat___Swellingofankles___Cough___Drycough___Coughingphlegm___Coughingblood___Shortofbreath___Asthma/wheezing___Frequentcolds___PaininribcageOther__________

Mental/Emotional___Difficultconcentrating___Poormemory___Worry___Anxiety___Depression

___Irritability___Frustrationoranger___Fearfulness___StressOther____________

DigestiveSystem___Nausea___Vomiting___Diarrhea___Constipation___Loosestools___Stomachpain___Abdominalpain___Poorappetite___Excessivehunger___Abdominalbloating___Belching___Indigestion___Acidreflux___Hemorrhoids___Historyofeatingdisorder

Urinary/Genital___Painfulurination___Difficulturination___Frequentdaytime___Nighttimeurination___Incontinence___Cloudyurine___Genitalpainoritch___Genitaldischarge___Lowsexdrive___Excessivesexdrive___HistoryofSTD_________

Female___Irregularperiods___Painfulperiods___Spotting___Passingclots___Scantyornoperiods___Earlyperiods___PMS___Menopausalsymptom___AbnormalPAPsmear___Vaginaldischarge___Breastlump___Breastpain/dischargeOther_____________

PatientInformation|HealthHistory|ConsentandRORTraditionalChineseMedicine–Acupuncture–HerbalMedicine

Themissionofthispracticeistoworkinpartnershipwithclientsusingacupunctureandlifestylemodificationtoremindthebodyofitsnaturalhealthystate.

Astheclient,Iunderstand:• Methodsortreatmentsmayinclude,butarenotlimitedto,acupuncture,acupressure,electricalstimulation

ofneedles,moxibustion,cupping,TuiNa(Chinesemassage),ChineseorWesternherbalmedicine,andnutritionalcounseling

• Ifthetreatmentseemscontraindicatedorinappropriate,thepractitionermaynotcontinuetreatmentorrefermetotheappropriatemodality.Conversely,Ihavetherighttoconsenttoorrefuseanyoftherecommendedtreatments

• Thatalthoughreasonableprecautionswillbetaken,Iamundergoingtreatmentsatmyownrisk.Suchriskmayincludeunforeseencomplicationsorbodilyinjury,noguaranteecanbemadeofasuccessfulresultorcure;slightpain,light-headednessornausea,soreness,bruising,bleedingordiscolorationoftheskinandinsomecasesmysymptomsmaytemporarilyworsenbeforetheybegintoimprove

• Anythingdiscussedintheclinicwillbeconfidential,withtheexceptionofinformationrevealedaboutchildrenbeingabusedorintendeddamagetopersonsorproperty.Thepractitionerislegallyresponsibletoreportsuchinformationtotheproperauthorities

• Asadiverseandintegrativeclinic,theremaybesituationswhereitisnecessarytosharemypersonalinformationwithUrbanWellnesspractitionerstoprovideoptimalcare,interventions,andservicestomytreatmentplan

• Theherbsandnutritionalsupplements(whicharefromplant,animalandmineralsources)thathavebeenrecommendedaretraditionallyconsideredsafeinthepracticeofChineseMedicine.Iunderstandthesameherbsmaybeinappropriateduringpregnancyandwillinformmypractitionerimmediatelyofpregnancystatus.IfIexperienceanygastrointestinalreactionstotheherbsIwillinformtheacupuncturistimmediately.

• Imustinformmypractitionerofanymajorpastorcurrenthealthissues,suchas:acarrierofanyinfectiousagents,pregnancystatus,fit,faintorotherodddetachedsensations,apacemakeroranyotherelectricalimplants,damagedheartvalvesorhaveanyotherparticularriskofinfection,ableedingdisorder;consumptionofanti-coagulants(bloodthinners)oranyothermedication

• ThefeesformytreatmentsarenotcoveredunderOHIPandmustbecoveredinfullbymyselforthroughthirdpartyinsurance:

o Initialconsultationandtreatment—$160.00(foradults)/$95.00(forchildrenunder16yearsofage)

o Follow-uptreatment—$95.00(foradults)/$45.00(forchildrenunder16yearsofage)o CommunityAcupuncture–InitialConsultationsandtreatment-$15+$30-$60(slidingscalerates)

/Follow-uptreatment–$30-$60(slidingscalerates)o Herbsandnutritionalsupplementfeesaredependentonthetreatmentplanoutlinedbythe

practitionerandpatient• Iwillpaythefullchargeofanymissedorforgottenappointmentswithout24-hournoticeofcancellation

(by5:00p.m.onbusinessdaysandby5:00p.m.FridayforMondayappointments)

Ihavediscussedthecontentofthisformwithmypractitioner.IacknowledgethatIhaveaskedanyquestionsImayhaveandreceivedanswersIunderstand.Bysigningthisform,IgivemyinformedconsentforTraditionalChineseMedicinetreatments.PatientSignature:_______________________________________________ Date:____________________________Practitionersignature:__________________________________________ Date:____________________________

PatientInformation|HealthHistory|ConsentandRORTraditionalChineseMedicine–Acupuncture–HerbalMedicine

I,_________________________________________,ormyappointedrepresentative__________________________________________ pleaseprint pleaseprint

☐ consent ☐ donotconsentforUrbanWellnessandFertilityTorontotocollectandreleasemygeneralpatientormedicalinformationtoothermedicalpractitionersorhealthcareproviders/supportworkers,emergencypersonneland/oranyotherrelevantorganizations.Intermsofinformation,UrbanWellnessFertilityTorontomaycollectanyotherthefollowing:

• Contactinformation• Personalorfamilymedicalhistory• Medicalinsuranceorbilling/accountinformation

Incasesofemergenciesorlifethreateningsituations,medicalorsupportstaffworkersmayhavetocollectthisinformationfromfamilymembersorotherlistedcontactswithoutyourpriorwrittenconsent.

HowYourInformationWillBeUsedYourpersonalinformationcanbeusedordisclosedforthefollowingreasons:

• Forbillingoraccountpurposes• Toassist3rdpartyinsurancecompanieswithinsuranceclaims• Referringyourmedicalhistorytoanotherhealthpractitionerorhealthcareprovider• Toseekadviceforpotentialtreatmentoptions• Topreventorassistpatientsincasesofemergenciesorthreattotheirhealthandsafety• Tofulfillanyobligationsasmandatedbylaw

PatientAccesstoInformationIunderstandthatmypersonalandmedicalhistoryisavailabletomeformyreviewundermostcircumstances.Caseswhereaccesstorecordscanbelimitedare:

• Incaseswhereaccesstoinformationcausesathreattoyourlifeorpersonalhealth• Wherethelawdisallowsaccesstoinformation• Intheeventwheredisclosureofinformationrelatestoanyanticipatedoractuallegalproceedingsor

professionalconductproceedings

AcknowledgmentIallowformedicalpersonneltouseanddisclosemyinformationasoutlinedabove.IunderstandthatIcanaccessmypersonalhealthinformationexceptasoutlinedabove.IunderstandthatIcanwithdrawmyconsentatanytime,butitmaydirectlyaffecttheservicesIcanreceive.Mypersonalinformationcanstillbeused/disclosedifmandatedbylaw.

AdditionalCommentsorRestrictions:_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________PatientSignature:_______________________________________________ Date:____________________________Witnessed:__________________________________________ Date:____________________________