Acupuncture/Chinese Medicine Client Information

Acupuncture/Chinese Medicine Client InformationName: ___________________________Date of Birth: ________________________Phone #: _________________________Admission Date: ______________________Address: _________________________________________________________________Complaint: _______________________________________________________________Referred by: ______________________________________________________________Medical History:

Have you ever had:Have you ever had or do you now have:

YesNo(check each item)YesNo(check each item)

SinusitisHay Fever

Heart AttackChest Pain

Stomach, Liver or Intestinal TroubleAsthmatic Wheezing

Tumor, Growth, Cyst, CancerIndigestion

Sugar or Albumin in UrinePainful Joints

Any Drug or Narcotic HabitBack Pains

Anxiety/Stress/Emotional ProblemsNeck Pains

Headaches

High Blood Pressure

Female Only: Are you currentlyNervousness

PregnantAuto Accident Related Problems

Nasal/Skin Allergy

Medications/Operations (Please list all performed and your age when each was performed):

_________________________________________________________________________

_________________________________________________________________________

X-Rays: __________________________________________________________________

Treatment (Radiation, PT/OT, Chemotherapy and Psychotherapy etc.)

_________________________________________________________________________

_________________________________________________________________________

I understand that the acupuncture treatments are safe. All needles are made with surgical steel, are sterile and only disposable needles are used. There is no medication in the needles.

I understand that during acupuncture treatments, there will be a feeling of slight pain when the needle punctures the skin. Sometimes there may be slight bleeding at the points where needles are removed. Some patients may experience dizziness, light-headedness, nausea or sweatingthese symptoms are called needle shock which are caused by the patient being anxious, nervous, fatigued, having an empty stomach or hypo- or hypertension. There symptoms are not life threatening. Upon removal of the needles, symptoms will immediately go away. To prevent needle shock, avoid having an empty stomach before treatment, relax, and advise the acupuncturist of any medical condition.

Date:

_______________________________

Signature: _________________________________________

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