Please just check boxes that apply – double click on the box and hit check

Name
Date
Address
Post Code
Date of Birth Age
Phone No. (Home)
Phone No. (Work)
Phone No. (Mobile)
Email
Emergency Contact
Tel Relationship

Doctor’s Name
Address
Phone No

Have you ever received the Following?

Acupuncture

Chinese herbal Medicine

Physiotherapy

Naturopathy

Massage

Osteopathy/Chiropractic

Any other

Main reason for visit: (e.g. Facial improvement of skin tone and lines)

Besides the reason above, list your main health concerns in order of importance to you:

Please indicate with a ‘P’ (past) ‘C’ (current) ‘F’ (family), if any of the conditions

Heart Conditions	Stroke	High Blood Pressure	Low Blood Pressure
Diabetes	Deep vein thrombosis	Neurological	Spinal/Head Injury
Respiratory Condition	Kidney Disorder	Cancer	Hepatitis
HIV/AIDS	Sprain/strain/ fracture	Osteoporosis	Headaches/Migraines
Jaw Pain	Arthritis	Dizziness/Fainting	Contagious Illness
Skin Condition	Digestive Problemsm	Haemophilia	Wear a pacemaker
Lung Condition	Epilepsy	Possible pregnancy	Upcoming surgeries
Pms	Thyroid Conditions	Multiple sclerosis	Endometriosis

Please list any prescription or over the counter medication you are currently taking:
1.	4.
2.	5.
3.	6.
Please list herbal medicine or other supplements you are currently taking:
1.	4.
2.	5.
3.	6.
Please list any allergies (food, drugs, environmental, etc.)
1.	3.
2.	4.
Have you ever been hospitalised and/or treated for infectious/serious conditions or surgeries? If yes, briefly explain for what condition or reason and when below.
Skin conditions – leave blank if not applicable
Do you have ulcerated or broken skin?
Have you ever seen a Dermatologist? If yes, when and why:
Have you ever had a skin allergy? If yes, when and to what:
Have you ever had a reaction to facial treatments? If yes, when and to what:
Do you have a history of cold sores of oral herpes?
Do you bruise easily?
Have you undergone any form of cosmetic procedure? Please give details: (Especially last two years e.g. Botox or fillers, rhinoplastry etc)
Could you be pregnant, planning a pregnancy or breastfeeding?
During pregnancy did you get hyper pigmentation or masking?
Do you sunbath or use sun beds regularly?
Do you suffer from loss of sensitivity in your skin?
Do you suffer from or have moles/warts/keloid scars?
What is your current skin care regime? Please list all products you use on your skin.

Please indicate your areas of concern

under eye area

smile lines

forehead lines

11’es frown lines between eyebrows

crows feet

Do you use the following and if so, how often?
Cigarettes:	Alcohol:	Drugs:	Coffee:	Fizzy drinks:

Do you participate in the following physical activities and if so, how often?
Yoga:	Running:	Fitness Class:	Gym:
Cycling:	Swimming:	Walking:	Other:

For each symptom below that you currently have, rate its severity from 1-5 (5 being the worst). Leave blank if N/A
Gan - Liver __ Irritability/frustration Depression Stress Emotional eating Unfulfilled desires Visual problems/floaters Blurred/poor night vision Red/dry/itchy eyes Headaches/migraines Dizziness Feeling of lump in throat Muscle twitching/spasm Neck/shoulder tension Brittle nails Sighing Sensation/pain under ribs PMS Genital itching/pain/rashes Xin - Heart Palpitations Chest pain/tightness Insomnia/sleep problems Restless/easily agitated Vivid dreams Lack of joy in life Forgetful Aversion to heat Bitter taste in mouth Tongue/mouth ulcers	Shen - Kidney Frequent urination Bladder infection Lack of bladder control Wake at night to urinate Feel cold easily Cold hands/feet Night sweats/hot flushes Low sex drive High sex drive Loss of head hair Hearing problems Crave salty foods Fear Poor long term memory Ankle swelling Tinnitus Fei - Lung Dry cough Phlegmy cough Nasal discharge/drip Sinus infection/congestion Itchy/painful throat Dry mouth/throat/nose Skin rashes/hives Snoring Grief/sadness Shortness of breath Allergies/asthma Weak immune system Alternate fever/ chills	Pi- Stomach Heaviness in head/body Fatigue after eating Difficult getting up in am Water retention Muscle tiredness/weakness Bruise easily Unusual bleeding (nose, stools) Bad breath Poor appetite Increased appetite Sweet cravings Poor digestion Nausea/vomiting Bloating/gas Haemorrhoids Constipation Loose stools Alternate constipation/loose Abdominal pain Intestinal pain/cramping Heartburn Pensive/over thinking Overweight Foggy mind Yeast infection Aversion to cold Cold nose Increased thirst Prefer warm drinks prefer cold drinks Sweat easily

On a scale of 1-10, how would you rate your daily energy levels (10 being best)
What is your occupation? Do you enjoy your work? How many hours per week do you work? Do you see daylight in your job? Is it stressful? Is your private life stressful, if so why?
Please describe in general what you eat and what you crave. (sweet, salty, organic, wheat, dairy, meat, vegetables, fruit, pasta, fast foods etc.)
How many times have you taken (approx.) Antibiotics Steroids
Are your bowel movements regular? How many times per day/week? Are they formed, loose, constipated or are they varied or difficult to pass? Do you have trouble falling asleep? Are you a light sleeper? How many hours sleep per night? Do you have vivid dreams? Do you wake up during the night? Do you find it difficult to get off back to sleep?
Do you experience urinary frequency, urgency, burning, dribbling, retention? What shade of yellow is your urine? Do you have a history of urinary tract infection? How much water do you drink in a day? Do you prefer it cold, warm or room temperature? Do you sip/gulp your water?

Female Patients only

Do you experience menstrual pain? When? Before the menses During (please specify which days) After What is the pain like? Stabbing Cramping Dull Heavy On/off What relieves the pain?

Do you experience Pre-menstrual symptoms? Which symptoms do you experience? Breast tenderness Cramps Acne Bloating Headache Change in bowel Nausea Moodiness Fatigue Night sweats Sleep disturbances Any other (list)

Have you ever been diagnosed with:
STD Pelvic inflammatory disease? Uterine fibroids Polyps Pelvic adhesions Prolapsed uterus Unique shape of uterus Endometriosis PCO Or PCOS	Date of last smear test _____/_____/_____ Have you ever had an abnormal smear test? Have you had a cervical biopsy/operation? Do you regularly get yeast infections? Do you regularly get bladder infections? If you answered yes to STD’s, then please list them.

Have you ever taken oral contraceptives? How long ? When did you stop? Have you ever had an IUD? Have you ever taken hormonal contraceptive
Is there anything else not discussed here that is important or relevant? Please elaborate here

Patient Information and Consent Form

Please read this information carefully, and ask if there is anything that you do not understand.

Whilst acupuncture has been shown to be highly effective in correcting energetic imbalances that can lead to certain conditions and to be effective in maintaining overall well-being, practitioners are required to advise that there may be some risks. Although practitioners cannot anticipate all the possible risks and complications that may arise with each individual case, you should be aware that the following side effects can occur. If there are any particular risks that apply in your case, your practitioner will discuss these with you.

What are the possible side effects of acupuncture?

Drowsiness can occur in a small number of patients, and if affected, you are advised not to drive

Minor bleeding or bruising can occur as a result of needling. The vasculature of the face is delicate especially around the eye area. Given the nature of the Advanced Cosmetic Acupuncture treatment, capillary bleeding can occur. Whilst this is not detrimental to the objective of the treatment it can be visible in the form of bruising for a number of days. To achieve maximum benefit in certain delicate areas of the face, bruising is sometimes unavoidable.

In less than 3% of patients, symptoms may become worse before they improve for 1-2 days following treatment. This is usually a good sign. Please let your acupuncturist know if your symptoms continue to worsen for more than 2 days.

Light headedness or fainting can occur in certain patients, particularly in the first treatment

Statement of Consent.

I confirm that I have read and understood the above information, and I consent to having treatment. I have read the possible risks of treatment outlined above, but do not expect the practitioner to anticipate and explain all possible risks and complications of treatment. I also understand that I can refuse treatment at any time.

I wish to rely on my practitioner to exercise judgement during the course of treatment which, based upon the facts then known, is in my best interests. I understand that the practitioner may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

By voluntarily signing below I show that I have read this consent to treatment, have been told about the risk and the benefits of treatment, have had the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and further conditions for which I seek treatment.

______ __________________ __ ________________________date

Print name in full Signature

Appointment Policy

if you are going to be more than 5 minutes late, please call to let us know.

A 24-hour notice for cancelled or rescheduled appointments is necessary in order to avoid a cancellation fee which is the cost of the full treatment price. This allows us time to schedule another patient who would also benefit from treatment. This appointment policy allows us to develop a mutual consideration and respect for our time and yours.

Any questions regarding my appointments have been addressed. I have read this statement and fully understand it.