Patient Information Questionnaire
Title:………… Family Name:……………………………………………………….Given Names:…………………………………..
Date of Birth:………/………/………….…..
Occupation:………………………………………………
Female
Male
Address:………………………………………………………………………………………………………………..Post code:……………
Phone:…………………………………..(Home) ……………………………….(Business Hours) …………………………………….(Mobile)
Email Address: .........................................................................................................................................................
Emergency contact name & phone (under 18y - guardian please sign): .........................................................
....................................................................................................................................................................................
Do you have pension card:
Yes
No
Expiry date: ............./............/.......................
Private Health Insurance Extras covering Acupuncture or Chinese Herbal Medicine?
(Please indicate Company)………………………………………………………………………………………………
Do you have any allergies, or suffered epilepsy or anaphylactic shock?
Yes
Yes
No
No
(If yes, please indicate)……………………………………………………………………………………………………………………………………
Do you have a tendency to bleed or bruise easily?
Yes
No
Are you pregnant or is there a possibility of being pregnant?
Yes
No
Have you had an adverse drug reaction or allergy?
Yes
No
Do you have a Heart Pace Maker or Stents?
Yes
No
Are you currently taking medications Warfarin or Digoxin?
Yes
No
Please list current medications:
Please list relevant medical history:
1)
1)
2)
2)
3)
3)
What is the main reason for coming today?
1)
2)
3)
I understand by signing this form that the information provided is true to the best of my knowledge.
Changes to the above should be advised upon future visits. I consent to receive proposed treatments
by the attending practitioner subsequent to discussing the benefit to my health. I also understand
that all bills are to be settled at the conclusion of each visit.
Signature:
(Guardian if applicable)
Date: _________________
Federation of Chinese Medicine & Acupuncture Societies of Australia Ltd. (FCMA)
All Information provided will be strictly confidential abiding to States and Commonwealth statutes.
This information enables practitioners to provide optimal health care. Please fill in the form carefully and thoroughly.