____________________________

(2c) What daily activities are you (9) Any problems with digestion?
finding difficult because of the (ie: bloating, heartburn)
above concerns? ______________
Confidential Health Information ____________________________
____________________________
Please Print Date:____________ ____________________________

Name:_______________________ (3) Is there a Family or Personal What type of food do you crave?
History of chronic disease? Please
Age:____ Date of birth: ________ describe. none sweet sour bitter
tart salty
Address: ____________________ ____________________________
(10) Constipation: Y N
____________________________ ____________________________ Diarrhea: Y N
Gas in bowels: Y N
Ph#: (h)__________(w)_________
(4) List Your Current Medications: (11) Any problems with urination?
Email: _______________________
____________________________ ____________________________
I would like to receive appointment
reminders by: Telephone Email ____________________________ (12) Females:

Occupation: __________________ ____________________________ Do you have a period? Y N

Physician: ___________________ ____________________________ regular irregular heavy

scant clots painful
(1) Please list your main less than 24-day cycle
complaints/concerns: (5) Allergies: Y N
Type_____________________ Days of flow: _________________
1.___________________________ ___
PMS symptoms : Y N
2.___________________________ (6) Respiratory Problems: Y N Breast tenderness: Y N
Type_____________________ Vaginal discharge:
3.___________________________ ___ none scant heavy

What treatments have you had in Do you smoke? Y N (13) Do you have problems with:
the past for these concerns?
(7) How is your sleep? Day sweats: Y N
____________________________ Night sweats Y N
____________________________
____________________________ (14) Thirst
Do you have trouble with:
increased normal decreased
(2a) History of Present Condition: Getting to sleep: Y N
Briefly describe the events, Staying asleep: Y N (15) Do you most often feel:
surgeries, etc. leading to your Nightmares: Y N
present concern. cold warm hot

____________________________ (8) Please circle the most Where?

appropriate choice(s). You may ____________________________
____________________________ circle more than one.
Do you have a fever or chills?
Appetite: increased normal Y N
(2b) Past History: decreased
Briefly describe your health history.
Eg. surgeries, illnesses, major Weight: increased normal
stresses, accidents, etc. decreased PLEASE TURN OVER

____________________________ Difficulty swallowing: Y N

 peace joy sadness fear
(16) Pain: If you have pain please (21) How is your concentration?
indicate the level: CONSENT FOR TREATMENT:
very good normal decreased
0 2 4 6 8 10
none worst (22) Heart palpitations: Y N I ______________________ grant
permission for and agree to
Type of pain: (you may circle more (23) Are your symptoms worse if receive Acupuncture, BodyTalk,
than one) the weather is: Physical Therapy, Counselling,
Herbs, Homeopathics, and/or
constant intermittent sharp hot cold damp dry windy related treatments, as deemed
burning aching throbbing necessary by Meridian
(24) The following will not prevent Acupuncture staff:
Location: ____________________ you from receiving therapy, but will
allow us to take the appropriate Megan Ewanowich BScPT,CBP,CMAc
____________________________ precautions. Holley Ziegler RN,BScN,CBP,RAc
Deeyana Baydala RAc ,RMT
Back pain: Y N Have you been diagnosed with:
Knee pain: Y N I understand that any information
Chest pains: Y N Hepatitis A, B, or C: Y N exchanged during treatment is
confidential in nature and will not
(17) Headaches: Y N Other blood or sexually transmitted be released without my prior
diseases: Y N written consent.
Where? forehead nape of neck
temple top of head Are you at risk for any of the I also understand that any missed
whole head above? appointment, without notice, will
incur a $40 fee. I agree to pay this
Dizziness: Y N Y N AIDS Hepatitis charge in full.
Fainting spells: Y N

(18) Energy: ___________________________

(25) Please add anything you think
Signature
is important.
very good normal decreased
___________________________
____________________________
Tired: morning noon Date
afternoon evening ____________________________
____________________________
(19) Changes in skin sensation: Witness
____________________________
Y N
____________________________
Describe_____________________ OFFICE USE ONLY:
____________________________
Numbness/Tingling: Y N
Where? Thank you for taking the time to
______________________ complete this questionnaire. A
thorough assessment of your
Trembling of hands or other parts of condition/concern is essential for
the body: Y N the careful planning of your
treatment.
Do you have problems with:
Hearing: Y N For your treatment comfort: Dress
Ringing in ears: Y N in loose, comfortable clothing and
Deafness: Y N leave jewellery at home. Allow at
Vision: Y N least 45 minutes per session.
dry eyes blurred
itchy painful
at least 24 hours
(20) Which of the following notification for cancellation of
emotions do you feel most often: appointments.
anger frustration resentment Thank you for your
irritability guilt anxiety kind consideration.