INITIAL INTAKE FORM Print Form E
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E-mail Form INITIAL INTAKE FORM Print Form PATIENT INFORMATION Today’s Date: Click here to enter a date Appointment Date: Click here to enter a date First name: Click here to Enter First name Last Name: Click here to Enter Last name Date of Birth? Enter Date of Birth Age: Enter Age Sex: Please choose Address Suburb: Suburb Postcode: Postcode Please supply email for appointments or invoices to be sent to you. Mobile: Phone (H): Phone (W): Email Address Mobile Number Phone Number Phone Number Street: Number and street Title: Please Choose Relationship status: Please Choose Name of Doctor: Address of Doctor: Doctor phone no.: GP Name GP Address Phone Number EMERGENCY CONTACT Emergency Contact: Relationship to Patient: Mobile: Emergency contact name Relationship Mobile Number Phone (W): HEALTH INSURANCE Do you have Private Health Insurance? If so, who are you insured with? Choose yes/no Does your insurance Cover Acupuncture? Health Insurer Choose yes/no HOW DID YOU HEAR ABOUT WELL WOMAN? Who told you about Woman? You chose Well Woman because you… Who referred you to Well Women Chose Well Woman because Please leave the name of the person who referred you so we can thank them! Click here to enter text. ENERAL 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 CHIEF COMPLAINT Current Condition. What brings you to Well Woman today? Condition #1 Condition #2 Page 1 of 6 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 Is your condition worse at different times of the day, months or seasons? Condition #1 Condition #2 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 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? Is there any relevant family History? Family History 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? Weeks Pregnant Are you needing our services for fertility/ IVF support Choose yes/no Have you ever had acupuncture from a Qualified Registered Chinese Medicine Acupuncturist before? (This does NOT include dry needling) Choose yes/no Page 2 of 6 HEALTH CHECKLIST Please ONLY Click YES if you are presently suffering or have suffered in the past any of the health conditions listed below ⃝ Recent weight GAIN ⃝ Recent weight LOSS ⃝ Fatigue ⃝ Cancer of any kind ⃝ Haemophillia ⃝ Have a Pacemaker ⃝ Infectious Disease ⃝ Heart Condition ⃝ On Blood Thinners ⃝ Epileptic ⃝ Seizures ⃝ Fainting Episodes Slow healing INTEGUMENTARY (SKIN) ⃝ Skin problems ⃝ ⃝ Psoriasis ⃝ Change in Moles ⃝ Bruise easily ⃝ Skin rash ⃝ Itching ⃝ Sores/Ulcers NEUROLOGICAL ⃝ Light headed/Dizziness ⃝ Memory Loss ⃝ Headaches ⃝ Migraines ⃝ Stroke ⃝ Concussion ⃝ weakness ⃝ Numbness/Tingling ⃝ Tremors ⃝ Bulging disc ⃝ Nerve impingement ⃝ Paralysis EYES, EARS, NOSE & THROAT ⃝ Vision Problems ⃝ Glaucoma ⃝ Blurred Vision ⃝ Double vision ⃝ Hearing loss ⃝ Ear Pain ⃝ Tinnitus (Ringing ears) ⃝ Ear infections ⃝ Mouth Sores ⃝ Sore throat ⃝ Hoarseness ⃝ Nose bleeds ⃝ Hyperthyroidism ⃝ Hypothyroidism ⃝ Diabetes ENDOCRINE (HORMONES) ⃝ Adrenal Fatigue RESPIRATORY ⃝ Cough ⃝ Coughing Blood ⃝ Pneumonia ⃝ Difficult breathing ⃝ Asthma ⃝ Chest Pain ⃝ Bronchitis ⃝ Emphysema CARDIOVASCULAR YES Heart Attack ⃝ Irregular heartbeat ⃝ Palpitations ⃝ Shortness of breath ⃝ Heart murmur ⃝ Cardiomegaly ⃝ Heart Murmurs ⃝ Pain/pressure in chest ⃝ High blood pressure ⃝ Low blood pressure ⃝ High cholesterol ⃝ Profuse sweating GASTROINTESTINAL ⃝ Nausea/vomiting ⃝ Abdominal Pain ⃝ Gallbladder problems ⃝ Liver problems ⃝ Hepatitis ⃝ Distress with greasy food ⃝ Gastric/Duodenal ulcer ⃝ Heartburn ⃝ Constipation ⃝ Diarrhoea ⃝ Colitis ⃝ Crohn’s disease ⃝ Irritable bowel Syndrome ⃝ Pancreatitis ⃝ Mucous in stool ⃝ Blood in stool Page 3 of 6 GENITOURINARY ⃝ Painful/Burning urination ⃝ Blood in urine ⃝ Frequent urination ⃝ Urinary tract infection ⃝ Incontinence ⃝ Night time urination ⃝ Loss of libido ⃝ Kidney stones ⃝ Bleeding disorders ⃝ Lymphoma ⃝ Clotting disorder/DVT HAEMATOLOGIC (BLOOD) ⃝ Anaemia MUSCULOSKELETAL ⃝ Arthritis ⃝ Osteo arthritis ⃝ Rheumatoid arthritis ⃝ Bone spurs ⃝ Tennis/Golfers elbow ⃝ Fibromyalgia ⃝ Frozen shoulder ⃝ Neck injury ⃝ Back injury ⃝ Spinal trauma ⃝ Birth trauma/defect ⃝ Muscle weakness ⃝ Osteoporosis ⃝ Muscular dystrophy ⃝ Scheurman’s disease ⃝ Joint pain ⃝ Gout ⃝ Scoliosis ⃝ Lupus ⃝ Spondyloisthesis ALLERGIC/IMMUNOLOGIC ⃝ Catch cold easily ⃝ Frequent sinus trouble ⃝ Frequent influenza ⃝ Fever ⃝ Allergies ⃝ Hayfever ⃝ Swollen glands ⃝ Glandular Fever WOMEN ONLY ⃝ Irregular Periods ⃝ Nipple Discharge ⃝ Pre Menstrual Tension ⃝ Hot Flushes ⃝ Menstrual Pain ⃝ Menstrual clots ⃝ Leucorrhea (Thrush) ⃝ Hysterectomy ⃝ Mastitis ⃝ Low milk supply ⃝ Breastfeeding difficulties ⃝ Lumps in Breasts ⃝ Endometriosis ⃝ Uterine polyps ⃝ Uterine Fibroids ⃝ Sub fertility ⃝ Pelvic Inflammatory Disease ⃝ Ovarian/Uterine Cancer ⃝ Abnormal pap smear ⃝ Polycystic Ovarian Syndrome ⃝ Prostate problems ⃝ Difficulty urinating ⃝ Prostate Cancer MEN ONLY ⃝ Burning Urination HEALTH PRACTITIONERS NOTES: FOR OFFICE USE ONLY Click here to enter text. Page 4 of 6 IVF & FERTILITY SUPPORT PATIENTS ONLY WESTERN DIAGNOSIS FOR INFERTILITY ⃝ Endometriosis ⃝ PCOS ⃝ High FSH ⃝ Low AMH ⃝ Unexplained ⃝ Tubal Blockage ⃝ Age ⃝ Male Factor ⃝ Socially Infertile ⃝ Recurrent miscarriage ⃝ Abnormal pap smear ⃝ Hysterectomy ⃝ Endometriosis ⃝ Polycystic Ovarian Syndrome ⃝ Uterine Fbroids ⃝ Sub fertility ⃝ Vasectomy ⃝ Vasectomy reversal ⃝ Variocele ligation ⃝ Un descended testes REPRODUCTIVE HISTORY Briefly describe your journey so far: Click here to enter text. Results of Blood tests & Scans Female Male ⃝ HSG Enter Results ⃝ HyCoSy Enter Results ⃝ Laparoscopy Enter Results ⃝ Ultrasound Enter Results ⃝ Semen Analysis Count(million cell/ml) Motility (%) Morphology (% Normal forms) PLEASE BRING ULTRASOUND REPORTS, SEMEN ANALYSIS REPORT & BLOOD RESULTS How many stimulated cycles have you had? # of Cycles Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 # Eggs Collected # Eggs Fertilized # Eggs Transferred FSH result Positive Pregnancy yes/no Date # Eggs Collected # Eggs Fertilized # Eggs Transferred FSH result Positive Pregnancy yes/no Date # Eggs Collected # Eggs Fertilized # Eggs Transferred FSH result Positive Pregnancy yes/no Date # Eggs Collected # Eggs Fertilized # Eggs Transferred FSH result Positive Pregnancy yes/no Date # Eggs Collected # Eggs Fertilized # Eggs Transferred FSH result Positive Pregnancy yes/no Date # Frozen # Frozen # Frozen # Frozen # Frozen How many Frozen transfers have you had? Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no Page 5 of 6 Date # Eggs Transferred Progesterone Yes/No Positive Pregnancy yes/no If you have had any IVF cycles cancelled please detail why? Cancelled IVF cycles If you have had any miscarriages? If so how many? Number of miscarriages Please read the following agreement carefully CANCELLATION POLICY 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. Due to the increasing demand for Well Woman services a cancellation fee of $25 will apply if less than 8 hours notice is given. Thank you for your understanding. For online bookings please state whether you agree I agree to Well Woman’s cancellation Policy Yes/ No Signed (at your first appointment) ______________________________________________________________________________Date: ______________ CONSENT TO CHINESE MEDICINE ACUPUNCTURE CARE I understand that as in all forms of health care, there may be some infrequent but possible side effects as a result of Acupuncture treatment. These may be: Fatigue: More commonly you will feel energized after a treatment but occasionally the ‘acu-land’ effect persists as your body readjusts to healing Soreness: Occasional soreness lingers for a short time after needles they are removed. Vigorous needle stimulation is never used at Well Woman Muscle soreness if massage therapy incorporated into treatment Some suction bruising may occur with cupping therapy Occasionally redness at the acupuncture site Very Rare- bruising at the acupuncture site The occasional person gets twitchy during acupuncture. Most patients just have a restful sleep Very Rare- Light headedness after acupuncture. Pneumothorax is extremely rare amongst qualified registered acupuncturists. Emotional Release: In acupuncture is usually a positive experience, but it can be surprising, especially for people who tend to be more stoic. Feeling worse: Whilst most people notice a marked improvement in their symptoms following acupuncture, occasionally patients feel worse before they start feeling better. The idea is that as your body starts undergoing the changes involved in moving toward health, things get stirred up. This can cause not only an exacerbation of current symptoms but also the recurrence of previous ailments that had been dormant. Once these are brought to the fore they can be dealt with and you can begin to move toward better health. I am assured by Elaine Pedley (Acupuncturist) 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. ONLINE: I agree to the above mentioned I give consent to treatment by Well Woman Yes/No AT INITIAL CONSULTATION Signed __________________________________________________________________Date: ______________ Please fill out this form and email back to bookings@wellwoman.com.au Or: print out and send via mail to 10 Rosedale Grove Frankston South Vic 3199 Page 6 of 6
