Positive Chinese Medicine Inc.
Date: ____________________
Health History Summary
First Name_________________ Last Name ____________________
Age__________ Birth Date_________________
Address ________________________________________________________________ Postal Code _______________
Phone (Cell) _______________________ (Home) ________________________ (Work) ____________________________
E-mail_______________________________ Occupation_____________________________
Marital Status: Sgl Mar Div Sep Wid Other:_________
Employer___________________
Number of Children __________________________
Emergency Contact_________________________ Relation______________________ Phone_______________________
How did you find out about my office? (Please circle) Friend by_____________ Fertility Clinic Medical Doctor by___________
Flyer,
Phone Book,
Website (ivf.ca / acufinder.com / acupuncture-fertility-ivf.com),
Magazine, Other:_________
Do you know someone who could benefit from a consult? Yes / no
(If you answered yes, please feel free to take our business card /brochure after your session.)
Your Current Health Problems
What is your main reason for coming in today? __________________________________________________________________
List in order of importance other health problems that are troubling you:
1) _________________________________________________________________
How long? _______________________
2) _________________________________________________________________
How long? _______________________
3) _________________________________________________________________
How long?________________________
Have you had acupuncture before? Yes / No
For what conditions? ____________________________________________
Have you had Chinese herbs before? Yes / No
For what conditions? ____________________________________________
Please circle all of the following complimentary health care practitioners you have seen:
Fertility specialist
Naturopathic Doctor
Chiropractor
Massage Therapist
Osteopath
Other:_____________________
What were the results? _____________________________________________________________________________________
General Health History
What is the general state of your health? Excellent
Good
Average
Fair
Poor
What is your current level of energy from 1 to 10 (where 10 is the best you have ever felt)? :__________
What is your current approximate weight? _________ One year ago?_________ Ideal weight?_________ Height?_________
Please list the 3 most significant stressful events in your life:
1) _______________________________________________________________
Date: ___________________
2) _______________________________________________________________
Date: ___________________
3) _______________________________________________________________
Date: ___________________
Are any of these situations continuing to impact your life? Yes / No (If yes, please circle number.)
Are you currently working with a professional counselor, psychologist, social worker, pastor or other therapist?__________
Have you in the past?__________________ When?____________________
Do you have any allergies to any drugs, herbs, foods, animals or other? Yes / No
Please specify: ____________________________________________________________________________________________
Have you had any major injuries? If so, what happened and when? __________________________________________________
Previous surgeries and hospitalizations (include dates) ____________________________________________________________
Rate the following symptoms from 1 to5 ( 5 being worst )
Xin ( Heart ) Condition
Palpitations
Insomnia
Chest Pain
Cankers
Depression
Anger
PMS
Breasts Tenderness or Pain
Bitter Taste in Mouth
Dry/Tiredness of Eyes
High Blood Pressure
Neck /Shoulder Tension
Muscle Twitching
High prolactin Levels
Gan ( Liver ) Condition
Pi (Spleen) Condition
Poor Appetite
Craving Sweet
Poor Digestion
Bloating
Loose Stools
Abdominal Pain
Fatigue
Water Retention
Dizziness
Bruise Easily
Feel Heaviness in the
Lighter
Menstruation
Worry/Over-thinking
Cold Hands &
Low Blood
Feet
Pressure
Mid Cycle Spotting
Allergies
Hypothyroidism
Anemia
head/body
Varicose Veins
Fei ( Lung ) Condition
Cough
Shortness of Breath
Sinus
Catch Cold easily
Skin Rashes
Snoring
Asthma
Shen ( Kidney ) Condition
Ringing in ears
Hearing loss
Loss of Hair
Poor Memory
Hot Flash
Lower Part of Body Swelling
Frequent Urination
Incontinence
Bladder Infection
Feel Cold
Low Libido
Which of the following do you currently use? (Please indicate how much, how often and how long.)
Alcohol
Tea
Antacids
Sedatives
Coffee
Tobacco
Hormones
Laxatives
Other Medications (Please give name, dose, and amount of time on the medication)
_____________________________________________________________________________________________________
Vitamins/Herbs: ________________________________________________________________________________________
Any other supplementation _______________________________________________________________________________
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Family History
Mother
Father
Sibling
Grandparent
Mother
Cancer
Kidney Disease
Tuberculosis
Diabetes
Heart Disease
Asthma
Stroke
Depression
High Blood
Other:
Pressure
_____________
Who do you currently live with? Spouse____
Partner____
Parents____
Are you currently in a happy and supportive relationship? (Please circle.)
Father
Friends____
Very
Mostly
Sibling
Grandparent
Children____
Somewhat
Alone____
No
What is your weakest organ system and why? (Example: Digestive, Immune, etc.)______________________________________
Personal Habits
Do you exercise? Yes / No
If yes, what do you do and how often? _______________________________________________
On a scale of 1-10, how would you rate the quality of your sleep (10 being great)
__________________
Do you have a problem falling asleep? ____
Staying asleep? ____
How many hours do you think you need? _____
Do you wake refreshed?________________
How is your body temperature, compared to others? Warmer
Do you enjoy your work? Yes/No
Cooler
How much do you sleep? _____hours
Average
Do you take vacations? Yes/No
How often do you get colds, flu, sore throats in a year? ____________________________________
Kidneys and Bladder
Have you had a bladder infection? Yes / No
How often? ________
How was it treated?
__________________
Do you have any burning sensation during or after urination? Yes / No
Have you in the past?
__________________
What color is your urine? (i.e. dark yellow, bright yellow, cloudy, pale, clear)
________________________________________
Does your urine have an odor (i.e. strong, sweet) ________________________________________________________________
Do you have any difficulty starting or stopping when urinating? Yes / No
Perspiration
Do you any difficulty perspiring? Yes / No Does your sweat have a strong odor? _______________________________
Do you perspire when exercising? Lightly Moderately Heavily
Do you perspire at times other than when you exercise? Yes / No When?____________________________________________
Digestion and Elimination
Do you have any problems with gas, bloating, or fullness after eating? Yes / No
How often is this a problem? Often Sometimes Never
How severe?____________________________________________
How long have you had this problem?_________________
How often do you have bowel
movements?____________________
Do you ever have any blood, mucous or undigested food in your stool? _______________________________________________
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Do you ever have black, tarry or gray stool? Yes / No
Do you ever have yellow or light colored stool? Yes / No
Do you ever have rectal itching? Yes/No
Are your stools formed or loose?
Do you ever have alternating constipation and diarrhea? Yes / No
Do you ever have to strain to pass stool? Yes / No
_________________________
If yes, how often? ________________________________
If yes, how often? _______________________________________
Do you pass gas (flatus) frequently?____________________ Do you burp frequently? ________________________________
Do your stools or gas have a strong disagreeable odor? Yes / No
Is there anything else you feel I should know about you?
_________________________________________________________________________________________________________
Additional information for male patients
General History
How often do you get up in the night to urinate? ______________
Has this increased recently?________________________
Any problems with getting or maintaining an erection? Yes / No
Do you have any sores on your penis? Yes / No
Any prostate problems? Yes / No Have you had your prostate examined? Yes / No When? _____________________________
Any sexually transmitted diseases?___________________________________________________________________________
Number of pregnancies fathered:
Have you had any hormone tests performed? Yes / No
What were the result?______________________________________________________________________________________
Semen Analysis

Volume :

Count:

Motility:

Morphology:

DNA fragmentation:

White Blood Cell:
Fertility treatment
Clinic name__________________________________________________ By Dr.___________________________
Month / Year__________________________________________________________________________________
Type of treatment_______________________________________________________________________________
Thank you for taking the time to fill in this lengthy questionnaire. It will be a valuable resource in understanding your health.
The information received here about you is strictly private and confidential
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Patient consent form
I _______________ (Name in print), voluntarily consent to receive (the following of my choosing), Acupuncture, Chinese Herbal
Medicine administered by Jing-lan Li Burns or Qi Dai who are registered to practice the specified treatment/ training. I understand
their training is in the specified treatment/ training and that they are not, nor claiming to be a medical doctor.
I understand that the evaluation given to me ( when receiving acupuncture) is an energetic assessment of the functioning of any
organs and the Qi ( energy) moving in the Acupuncture Meridian Network; it in no way purports to be, or replaces allopathic
(western) medical evaluation, diagnosis, or treatment.
I shall provide a full history and description of complaints which is complete and accurate. I understand that the need for
communication with all of my health care providers regarding my health status is ongoing and necessary. I understand that no
guarantee has been made concerning the use and effects of Acupuncture, Chinese Herbal Medicine. I understand that I may stop
treatment at any time.
I understand that Acupuncture is the insertion of fine sterile needles, with or without the addition of electrical stimulation, through
the skin, and / or the application of heat to regulate and balance Qi, improve organ function and improve health.
I acknowledge that, although rare, certain side effects may result from Acupuncture, heat therapy and Chinese Herbal Medicine.
These may include minor bruising, minor bleeding, some pains at the site of needle insertion, dizziness or fainting. These events
are unusual and of short duration. Rare but potential side effects of heat therapy include heat discomfort or burning. Side effects of
Chinese Herbal Medicine are rare but may include allergic reactions. Strong cleansing responses to Acupuncture and Chinese
Herbal Medicine may also occur. Potential effects will be addressed.
I am choosing Acupuncture and /or Chinese Herbal Medicine as an exercise of my right to freedom of choice in the healing arts.
Signature: ____________________________________________________________
Date:_____________________________
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