Well Woman & Family Acupuncture
17 Ranelagh Drive,
General
Mount Eliza, 3930
Phone: 03 9787 8288
Family
Health Form
bookings@wellwoman.com.au
PATIENT INFORMATION
Today’ s Date: Enter a date
Appointment Date: Enter a date
First name: Enter First name
Last Name: Last name
Date of Birth? Enter Date of Birth
Age: Enter Age
Address
Street: Number and street
Title: Ms/Mr/Dr
Relationship status: Please choose
Sex: Please choose
Suburb: Suburb
Postcode: Postcode
Please supply email for appointments or
invoices to be sent to you.
Mobile:
Phone (H):
Phone (W):
Email Address
Phone Number
Phone Number
Phone Number
Name of Doctor:
Doctor phone no.:
Address of Doctor:
GP Name
Phone Number
GP Address
EMERGENCY CONTACT
Emergency Contact:
Relationship to Patient:
Emergency contact name
Relationship
Mobile:
Phone (W):
Mobile Number
Phone Number
HOW DID YOU HEAR ABOUT WELL WOMAN?
How did you hear about Well Woman Family
Acupuncture?
Chose Well Woman because
Who referred you to Well Women
Who told you about Woman?
Please leave the name of the person who referred you so we can thank them! Click here to enter text.
Tick if you have had TCM Acupuncture in the past?
Tick if you have had Chinese Herbs before?
GENERAL INFORMATION
Occupation: Occupation
Duties:
Duties if relevant to condition
Would you like to be on our mailing list for
events and free health workshops:
Choose yes/no
Do you have a Pension, health care or
veteran’s affairs card?
Card Number: Card Number
Expiry Date:
Expiry Date
REASON FOR VISIT?
What brings you to Well Woman today?
Reason #1
Reason #2
How long have you had this/these condition (s). When did you first notice it?
Condition #1
Condition #2
Prior Treatment(s) for this condition? If so, what treatment and did it help?
Condition #1
Condition #2
What Makes your condition better? What makes it worse?
Condition #1
Condition #2
Please complete, ‘Save as’ ‘Your Name.Pregnancy’ and email ASAP before your initial appointment. Thank you
Page 1 of 5
www.wellwoman.com.au
Well Woman & Family Acupuncture
17 Ranelagh Drive,
General
Mount Eliza, 3930
Phone: 03 9787 8288
Family
Health Form
bookings@wellwoman.com.au
GENERAL HEALTH
What (if any) exercise do you do? Exercise regime
If you smoke, how many cigarettes do you smoke a day? No. of cigarettes
How much tea, coffee, energy drinks do you drink per week? Caffeinated drinks
Have you ever taken or presently take any drugs of addiction? If so, what? Drugs/medications
How much alcohol do you drink per week? Alcoholic drinks
MEDICAL HISTORY
What (if any) MEDICATIONS or supplements are you on? List of Medications and/or Supplements
Do you have any Allergies to any medications? Choose yes/no
If Yes What medication are you allergic to and what reaction do you have?
Do you have any Allergies to tape/ foods/ Contact dermatitis? Choose yes/no
If Yes What materials or food are you allergic to and what reaction do you have?
Do you have any children? If so how many? Click here to enter text.
Are you pregnant? Choose yes/no
If Yes, how many weeks Gestation at time of appointment? Weeks Pregnant
HEALTH CHECKLIST
Please indicate with PAST, CURRENT or FAMILY medical History if any of the conditions below apply
Heart Condition
Past/Current/Family
Stroke
Past/Current/Family
High Blood Pressure
Past/Current/Family
Low Blood Pressure
Past/Current/Family
Diabetes
Deep Vein Thrombosis
Past/Current/Family
Neurological Conditions
Past/Current/Family
Spinal or Head Injury
Past/Current/Family
Kidney Disorder
Past/Current/Family
Cancer
Past/Current/Family
Recent weight Gain/Loss
Past/Current/Family
Sprain/Strain/Fracture
Past/Current/Family
Osteoporosis
Past/Current/Family
Headaches/Migraines
Past/Current/Family
Past/Current/Family
Arthritis
Past/Current/Family
Dizziness/Fainting
Past/Current/Family
Contagious Illness
Past/Current/Family
Skin Condition
Past/Current/Family
Digestive Problems
Past/Current/Family
Haemophiliac
Past/Current/Family
Wear a pacemaker
Past/Current/Family
Lung Conditions
Past/Current/Family
Epilepsy Past/Current/Family
Possibility of Pregnancy
Past/Current/Family
Upcoming Surgeries
Past/Current/Family
Anxiety
Depression
Past/Current/Family
Other: ..............
Past/Current/Family
Respiratory Condition
Past/Current/Family
HIV/AIDS
Past/Current/Family
Hepatitiis
Past/Current/Family
Diagram to be filled out at appointment
Ple
cur
Sensations/pain characteristics
Dull
Sharp
Severe
Burning
Stabbing
Shooting
Throbbing
Moving
Tingling
Please complete, ‘Save as’ ‘Your Name.Pregnancy’ and email ASAP before your initial appointment. Thank you
Page 2 of 5
www.wellwoman.com.au
Well Woman & Family Acupuncture
17 Ranelagh Drive,
General
Mount Eliza, 3930
Phone: 03 9787 8288
Family
Health Form
bookings@wellwoman.com.au
Numbness
FEW QUESTIONS
On a scale of 1-10, how would you rate your daily energy level (10
being best)? ..............
Do you experience urinary frequency, urgency, burning, dribbling, or
retention? What colour/shade of yellow is it? Do you have a history
of urinary tract infections?
1. ......
..............
What is your occupation? Do you enjoy your work? How many hours
per week do you work? Is it stressful? What are your duties?
..............
How many glasses of water do you drink in a day? ..............
3. .
Are your bowel movements regular? How many times per
day/week? Are they formed, loose, constipated, or do they
alternate from loose to difficult to pass? ...............
Please describe in general what you eat, and what do you
crave? (sweet, spicy, salty, organic, wheat, dairy, meat, veggies,
fruit, pasta, sandwiches, soups, etc.) ..............
5. .
Do you have trouble falling asleep? Are you a light sleeper?
How many hours per night? Do you have vivid dreams? If so,
what are they about? Wake and have difficulty falling back to
sleep? ..............
Describe yourself from an emotional standpoint, what would you say (i.e.
irritable, worrier, anxious, sad, impatient, stressed etc.) ..............
Ple
FOR EACH SYMPTOM BELOW THAT YOU CURRENTLY HAVE, RATE ITS SEVERITY FROM 1-5 (5 BEING WORST). LEAVE BLANK IF N/A
1. .
Gan (LR)
Shen (KI)
Pi (SP)
1-5 Irritability / frustration / impatient
1-5 Frequent urination
1-5 Heaviness in the head / body
1-5 Depression / Stress
1-5 Bladder infection
1-5 Fatigue / after eating
1-5 Emotional eating
1-5 Lack of Bladder control
1-5 Difficult getting up in morning
1-5 Unfulfilled desires
1-5 Wake to urinate
1-5 Water retention
1-5 Visual problems / floaters
1-5 Feel cold easily
1-5 Muscular tired / weak
1-5 Blurred vision / poor night vision
1-5 Cold hands / feet
1-5 Bruise easily
1-5 Red / Dry / Itchy eyes
1-5 Night sweats / hot flushing
1-5 Unusual bleeding (stool, nose, etc)
1-5 Headaches / Migraines
1-5 Low sex drive
1-5 Bad breath
1-5 Dizziness
1-5 High sex drive
1-5 Poor appetite
1-5 Feeling of lump in throat
1-5 Loss of head hair
1-5 Increased appetite
1-5 Muscle twitching / spasm
1-5 Hearing problems
1-5 Crave sweets
1-5 Neck / shoulder tension
1-5 Crave salty food
1-5 Poor digestion
1-5 Brittle nails
1-5 Fear
1-5 Nausea / vomiting
1-5 Sighing
1-5 Poor long term memory
1-5 Bloating / gas
1-5 Sensation or pain under rib cage
1-5 Ankle swelling
1-5 Haemorrhoids
1-5 PMS
1-5 Tinnitus
1-5 Constipation
1-5 Genital itching / pain / lesions
1-5 Loose stool
Fei (LU)
1-5 Alternate constipation / loose
Xin (HT)
1-5 Dry cough
1-5 Abdominal pain
1-5 Palpitations
1-5 Cough with Phlegm
1-5 Intestinal pain / cramping
1-5 Chest pain / tightness
1-5 Nasal discharge / drip
1-5 Heartburn
Please complete, ‘Save as’ ‘Your Name.Pregnancy’ and email ASAP before your initial appointment. Thank you
Page 3 of 5
www.wellwoman.com.au
Well Woman & Family Acupuncture
17 Ranelagh Drive,
General
Mount Eliza, 3930
Phone: 03 9787 8288
Family
Health Form
bookings@wellwoman.com.au
1-5 Insomnia / Sleep problems
1-5 Sinus infection / congestion
1-5 Pensive / over-thinking
1-5 Restless / easily agitated
1-5 Itchy / painful throat
1-5 Overweight
1-5 Vivid dreams
1-5 Dry mouth / throat / nose
1-5 Foggy mind
1-5 Lack of joy in life
1-5 Skin rashes / hives
1-5 Yeast infection
1-5 Forgetful
1-5 Snoring
1-5 Aversion to cold
1-5 Aversion to heat
1-5 Grief / sadness
1-5 Cold nose
1-5 Bitter taste in mouth
1-5 Tongue / mouth ulcers / cankers
1-5 Shortness of breath
1-5 Increased Thirst
1-5 Allergies / asthma
1-5 Prefer Warm drinks
1-5 Weak immune system
1-5 Alternate fever / chills
1-5 Prefer Cold drinks
PATIENT INFORMATION AND CONSENT FORM
Please read this information carefully, and ask your practitioner if there is anything that you do not understand.
While acupuncture, Chinese Medicine and other treatments provided by this clinic have proven to be highly effective in correcting
conditions and maintaining overall well-being, practitioners are required to advise patients 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 effect can occur. If there are 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 from acupuncture;
• 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 advise your acupuncturist if worsening of symptoms continues for more than 2 days;
• Fainting can occur in certain patients, particularly at the first treatment;
What are the possible side effects of Chinese Medicine and other treatments provided at this clinic?
• Bruising (looks like a circular hickey) is a common side effect of cupping;
• The herbs and nutritional supplements from plant, animal and mineral sources that have been recommended are traditionally
considered safe in the practice of Chinese Medicine, although some may be toxic in large doses or inappropriate during pregnancy.
Is there anything your practitioner needs to know?
Apart from the usual medical details, it is important that you let your practitioner know:
• If you have ever experienced a fit, faint, or other odd detached sensations;
• If you have a pacemaker or any other electrical implants;
• If you are pregnant;
• If you have a bleeding disorder;
• If you are taking anti-coagulants (blood thinners) or any other medication;
• If you have damaged heart valves or have any other particular risk of infection.
Statement of Consent
I confirm that I have read and understood the above information, and I consent to having treatments and procedures from this clinic. I have read
the possible risks of treatment outlined above, but do not expect the practitioner to be able 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 judgment during the course of treatment which, based upon the facts then known, is in my best
interests. I understand 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 risks and benefits of treatments
provided by this clinic, and have had an 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.
Privacy Policy
The information received and collected about our clients/patients from their visit to Well Women & Family Acupuncture is strictly private
and confidential. It is used and viewed only by the healthcare professionals and staff employed by Well woman , unless, in the best interest
of the client/patient, a practitioner determines that there is a need to communicate with another person or healthcare professional
outside of Well Woman.
Please complete, ‘Save as’ ‘Your Name.Pregnancy’ and email ASAP before your initial appointment. Thank you
Page 4 of 5
www.wellwoman.com.au
Well Woman & Family Acupuncture
17 Ranelagh Drive,
General
Mount Eliza, 3930
Phone: 03 9787 8288
Family
Health Form
bookings@wellwoman.com.au
I am assured by Well Woman that any questions I may have about my proposed care will be fully and honestly answered to the best of her
ability. I agree to rely upon her judgment, based on her knowledge of the facts of my condition at any time, to use the treatment most
suited to my condition.
I understand this consent form will cover the entire course of my treatment for current and any future condition(s) for which I seek treatment from
her. I understand my consent may be withdrawn by me at any time. I agree to my Acupuncturist communicating and seeking any information
deemed necessary from my medical doctor.
For online bookings please state whether you agree
I Give Consent to Treatment
Signed (at your first appointment) _________________________________________________________Date: ______________
Please read the following agreements carefully
APPOINTMENT POLICY
Welcome to Well Woman & Family Acupuncture. We are delighted to have you as a patient and look forward to providing you with the highest quality
care. In order to optimize your relationship with us, please take a minute to read our appointment policy.
Many of our clients are pleased to find out that we are usually on time. This is because a treatment room has been reserved for you. Well Woman
understands that there are times when you will need to cancel or reschedule your appointment. We are pleased to try and accommodate your needs.
Occasionally, there is a problem with patients who are not used to staying on schedule themselves. With that in mind, if you are going to be more
than 15 minutes late, please call to confirm availability.
A 24 hour notice for cancelled or rescheduled appointments is necessary in order to avoid a cancellation fee of $60. This allows us time to
schedule another patient that would also benefit from treatment. This appointment policy allows us to develop a mutual consideration and
respect for our time and yours.
Thank you for your understanding.
Any questions regarding my appointments have been addressed. I have read this statement and fully understand it.
For online bookings please state whether you agree
I agree to appointment policy
Signed (at your first appointment) ______________________________________________________Date: ______________
Please complete, ‘Save as’ ‘Your Name.Pregnancy’ and email ASAP before your initial appointment. Thank you
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