Courtland Acupuncture
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TAI-CHI and QIGONG
MINDFULNESS
CONTACT
BOOK AN APPOINTMENT
HOME
TEAM
ACUPUNCTURE & MASSAGE
COOL LASER THERAPY
SHIATSU MASSAGE
COUNSELLING
TELE-COUNSELLING
TAI-CHI and QIGONG
MINDFULNESS
CONTACT
Courtland Acupuncture
BOOK AN APPOINTMENT
GENERAL INFORMATION
Name
*
First Name
Last Name
Date of Birth
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Sex
Female
Male
Other
Gender you identify with
Address
Marital Status
Email
Cell Phone
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Daytime Phone
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Home Phone
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Emergency Contact: Phone #, Name, Relationship to Patient
Family Doctor: Name, City, Phone #
Main Occupation(s)
How did you hear about us?
Have you had Acupuncture before. If yes, with whom?
Have you had Shiatsu massage before. If yes, with whom?
May we send occasional emails / newsletters about our clinic updates, or Tai-Chi and other classes that we offer?
Yes
No
Thank you for filling the form below. It will help us understand better what your health issues are about, applying the hoslistic approach of Acupuncture and Traditional Chinese Medicine
CURRENT HEALTH CONCERNS
Main Issue you would like help with (Chief Complaint):
When did it start? What caused it?
Indicate the level of pain if any (0 = no pain, 10 = worse pain you've had). Describe what you feel. What makes it better, what makes it worse? Did you get a diagnosis, are your receiving treatments, which ones? How does it affect your life? What have you done to help it so far?
Other concerns you would like help with?
MEDICAL HISTORY
Past and Present Medical Conditions
Alcohol, substance abuse
Allergies/Asthma
Anemia
Arthritis
Autoimmune
Blood or bleeding disorder
Cancer
Chronic Fatigue/Fibromyalgia
COPD / Emphysema
Dementia
Depression/Anxiety/Mental Condition
Diabetes
Digestive Disorder
Eating Disorder
Epilepsy/Seizures
Gall bladder issues
Glaucoma
Gout
Heart Disease/Stroke
Hepatitis/Liver Disease
High Blood Pressure
Low Blood Pressure
Headaches / Migraines
High Cholesterol
HIV Positive / AIDS
Kidney Disease
Measles
Mumps
Multiple Sclerosis
Neurological Condition
Osteoporosis
Parkinson's Disease
Pneumonia, Bronchitis
Skin Disease
Thyroid: hypo-thyroid (under active)
Thyroid: hyper-thyroid (over active)
Veins issues (varicose, phlebitis, ulcers...)
Vertigo, dizziness
Other diagnosis:
INJURIES, SURGERIES, HOSPITALIZATIONS: please list with dates
MEDICATIONS: please list current prescriptions and what they are for
SUPPLEMENTS AND NATURAL REMEDIES: please list
How was your health when you were a child / teen? Birth trauma, prone to illnesses, lots of antibiotics, stressful / dysfunctional home, allergies, traumas etc?
Family Health History (Father, Mother, Other)
HEALTH AND LIFESTYLE
Weight and height
Work Hours Per Week
Number of days of vacation each year
Sleep Hours Per Night
Exercise Type and Frequency
Special Diet or Food Sensitivity
Caffeine/Smoke/Acohol/Substance Use & Frequency
What do you typically have for breakfast?
What do you typically have for lunch?
What do you typically have for dinner?
What snacks do you typically have, and when?
Energy Levels
HIGH
AVERAGE
LOW
EXTREMELY LOW
Stress Levels
LOW
AVERAGE
HIGH
EXTREMELY HIGH
MEN'S HEALTH
Any reproductive or men's health issue?
Number of children
MUSCULO-SKELETAL / BODY OVERVIEW
Check what applies to you
Headaches, migraines
Head concussion
Neck pain
Upper back pain
Mid back pain
Lower back pain
Tailbone pain / injury
Herniated disc(s)
Shoulder pain
Arm pain
Wrist / hand pain
Groin pain
Hip pain
Leg pain
Ankle / foot pain
Muscles cramps or spasms
Edema, swelling
Numbness
Osteoporosis, brittle bones
Chest pain
Stomach, abdominal pain
Metal implants, mesh, artificial joint (eg knee, hip replacement)
Pacemaker
Arthritis
Bruising easily
Body or parts of body feel heavy
Organs prolapse
Hernia
Please list the scars you have (where, why)
Other:
HEALTH INDICATORS
Hot and Cold
Feel usually warm / hot compared with others
Feel usually cool / cold compared with others
Cold hands
Cold feet
Hot hands
Hot feet
Have sweating sometimes without exercise
Prefer ice in drinks or cold drinks
Prefer warm drinks
Night sweats
No sweat, even when exercising
Sweat too much most of the time
Body sensitive to dampness or weather change
Fever, low grade fever
Very thirsty
Not thirsty
Tend to drink in sips
Other
Sleep
Usually sleep deprived
Poor sleep
Difficulty falling asleep
Difficulty staying asleep
Not rested in the morning
External disturbances eg street noises, light, baby
Wake up to urinate
Like to stay up late at night (evening person)
Like to get up early in the morning (morning person)
Sleep apnea
CPAP machine
Other
Psycho-emotional
Stressed
Anxious
Restless
Panic attacks
Depressed
Sad
Irritable
Angry, frustrated, resentful
Fearful
Indecisive
Frequent sighing
Poor memory
Difficulty to concentrate
Cloudy / foggy mind
Hyperactive
ADHD
Bipolar
PTSD
Autism, Asperger
Seasonal Mood Disorder
Burn-out
Addictions
Abuse survivor
Emotional trauma, grief
Suicidal
Other
Digestion
Poor appetite
Excessive appetite
Craving sweets
Craving salty foods
Craving hot / spicy foods
Heart burns, acid reflux
Nausea, vomiting
Bloated, gas
Loose stools
Diarrhea
Constipation
IBS
Stomach pain
Colitis, diverticulitis
Crohn's
Hemorrhoids, fistules
Other
Respiratory
Post nasal drip
Sinus issues
Ear infections
Lungs infection
Cough
Yellow / green phlegm (cough or nasal discharge)
Clear phlegm (cough or nasal discharge)
Blood in phlegm (from cough or nasal discharge)
Often sick with colds or flus
Asthma, wheezing
Shortness of breath
Allergies, others:
Urinary
Frequent urination
Difficult urination
Painful urination
Urgent urination
Blood in urine
Bladder infections
Kidney infections
Kidney stones
Other
Would you like to add anything else?
Thank you for submitting your intake, it will be added to your confidential medical file.