Lynn Plautz RAc RRT
MASSAGE AND THERAPY CENTRE 158 E 11th AVE VANCOUVER BC V5T2C2
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Name:
Gender:
Address:
City:
M
Age:
Prov:
Phone #:
Email:
Date of Birth:
Emergency contact name and number:
Employer:
F
P.Code:
Today’s DATE:
Occupation:
Physician name and contact info:
How did you hear of our clinic?
Have you been had acupuncture before?
If so, when?
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Y
N
/
Main Concerns:
1. _______________________________
2.________________________________
3.________________________________
If applicable, please mark areas of concern on diagram--
Relevant Health History:
(ie. Diagnosis, surgeries, injuries, procedures, diets, habits, medications…)
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Energy:
Digestion:
[_] high
[_] very low
[_] wired/frenetic
[_] ungrounded
[_] fatigue
[_] heavy limbs
[_] shortness of breath
[_] heart palpitations
[_] high/lo blood pressure
[_] hard to concentrate
[_] dizziness
[_] headaches
Sleep:
Temperature:
Emotions:
[_] loose stools
[_] # hours / night
[_] usually hot
[_] anger
[_] stools keep shape [_] hard to fall asleep [_] usually cold
[_] irritability
[_] diarrhea
[_] wakes easily
[_] dislike wind
[_] anxiety
[_] constipation
[_] restless sleep
[_] night sweats [_] depression
[_] gas
[_] dream a lot
[_] sweat easily
[_] worry
[_] bloating
[_] night mares
[_] chills
[_] grief
[_] belching
[_] don’t feel rested [_] cold hands
[_] sadness
[_] poor appetite
and feet
[_] fear
[_] nausea
[_] hot flashes
[_] shy/timid
[_] heartburn
[_] thirsty a lot
[_] obsessive
[_] thirst but no
thinking
desire to drink [_] joy
Moisture:
[__]
[__]
[__]
[__]
[__]
[__]
[__]
[__]
[__]
[__]
[__]
[__]
[__]
Dry skin
Dry hair
Dry eyes
Dry mouth
Dry lips
Dry throat
Dry nose/nosebleeds
Edema/swelling
Rashes
Itching
Oily skin
Pimples
Weight gain/loss
[__]
Eyes/Ears/Nose/Throat:
[__] poor vision
[__] red eyes
[__] itchy eyes
[__] floaters
[__] sinusitis
[__] poor hearing
[__] ringing in ears
[__] post nasal drip
[__] frequent colds
[__] sore throat
[__] cough
Menses:
:
[__] heavy periods
[__] light periods
[__] painful periods
[__] irregular periods
[__] cramps
[__] mood changes
[__] Clotted blood
[__] fatigue
[__] digestive changes
[__] yeast infections
[__] pregnant
[__] menopause
other____________________________________________
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Informed Consent to Acupuncture Care and Treatment:
I understand that these treatments are all safe, natural methods of healing and I recognize the
potential risks and benefits of these procedures as described below.
Potential Benefits: Relief of presenting symptoms, improved health and well being,
reduced stress and an overall balance of bodily energies which may lead to prevention or
elimination of your main health complaints(s).
Potential Risks: Acupuncture- although uncommon, there is a potential for acupuncture
to cause temporary bruising, swelling, bleeding, numbness, tingling, and soreness at the
needle site that may last a few days. Unusual risks of acupuncture include dizziness, fainting,
nerve damage or possibly the aggravation of symptoms existing prior to treatment.
Infection is a slight possibility even though our clinic uses only sterile single-use
disposable needles and maintains a clean and safe environment.
I will notify my acupuncturist if I am pregnant, should I become pregnant, or I am in
the process of trying to get pregnant so that my practitioner can avoid points that could
induce premature labor or miscarriage.
I have read, or have had read to me, the above consent. I have also had an
opportunity to ask questions about its content, and by signing below I agree to the
above named procedures. I intend this consent form to cover the entire course of
treatment for my present condition and for any future condition(s) for which I seek treatment.
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Patient’s name
___________________________
Signature
___________________
Date
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*********************For practitioner use only: *******************************
Pulse:__________________________________________________________
Tongue: ________________________________________________________
Diagnosis: ______________________________________________________
Treatment plan: _________________________________________________
Signature: