LifeHealthMassage Therapeutic Clinic
Massage Therapy, Physiotherapy, Chiropractic, Osteopathy, Orthotics,
Naturopathy, TCM (Herbal Medicine, Acupuncture, Moxibustion)
Ph: 416 502 0123,
647 708 9986
Traditional Chinese Medicine Patient Intake Form
Last Name:________________
Address:____________
___ First Name:__________________ Date:___________ __
_Apt #____City/Province_____
_
_Postal Code___
Date of Birth:_____________________________ Occupation: ____________________________
Home Phone: _____________________ Cel #: __________________Work#: ________________
E-mail: _________________________Would you like to be on our seasonal e-mailing list? Yes / NO
Have you ever been treated with traditional Chinese medicine? YES / NO
*If so, please circle any treatments you have received
Acupuncture
Tuina Massage
Physicians
Moxibustion
Herbal Medicine Cupping Other:___________
Emergency Contact
Current Medication
Chief complaint for treatment
Family Medical History
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Allergies
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Cancer
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Seizures
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Diabetes
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Stroke, Heart Attack
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Alcoholism
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Asthma
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High Blood Pressure
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Other
Your Past medical History (with dates)
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Allergies
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Cancer
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Seizures
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Diabetes
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Stroke, Heart Attack
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Alcoholism
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Asthma
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High Blood Pressure
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Surgeries
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Venereal disease
Thyroid deisease
Birth trauma
Chindhood illness
Accidents/significant trauma
Other
Please note that acupuncture and moxibustion are very safe. Occasional bruising, post needling sensation and minor burn may
happen. Fainting may occur for new patients due to nervousness, hunger or extreme tiredness. Herbal medicine are also very safe
and effective when recommended by a qualified TCM practitioner. Occasional abdominal upset, diarrhea, insomnia and sweating
may happen although this can be the response of the body to the treatment. If you have any concerns please do not hesitate to ask.
Acupuncture/Herbal medicine and moxibustion are safe and effective for the prevention and treatment of a wide range of health
problems, and for the promotion of general well being. Although TCM are helpful for many health conditions, it is not intended to
replace any tests or treatments recommended by your physicians. Please continue your medication prescribed by your physician
while you receive TCM services at this clinic.
Exemption of Liability clause:
I _____________________________hereby request and consent to receive traditional Chinese medical treatments including
acupuncture, herbal medicine, and moxibustion from a TCM Practitioner of LifeHealthMassage Therapeutic Clinic. I testify that the
above treatments and all its ramifications have been fully explained to me.
___________________________
Name of Patient
_____________________________
Signature of Patient
__________________________
Date
Your Lifestyle

Alcohol
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Marijuana
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Regular Exercise
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Tobacco
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Drugs
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Occupational Hazards
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Stress
General Symptoms
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Poor Appetitie
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Recent weight loss
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Wake up with not rested
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Chills
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Fever
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Heavy appetite
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Heavy sleep
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Bodily heaviness
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Night sweats
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Bleed or Bruise easily
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Strongly like cold drinks
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Poor sleep
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Cold hands & feet
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Sweats easily
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Fatigue
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Strongly like hot drinks
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Restless sleep
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Poor circulation
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Muscle cramps
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Lack of strength
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Recent weight gain
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Dream disturbed sleep
Head, Eyes, Ears, Nose, Throat
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Glasses
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Night blindness
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Jaw Tension
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Swollen glands
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Migraines
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Eye strain
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Glaucoma
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Canker sores(lips/tongue)
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Lumps in throat
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Concussions
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Eye pain
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Cataracts
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Dry mouth
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Enlarged thyroids
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Other
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Red eyes
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Teeth problems
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Excessive saliva
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Nose bleeds
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Dry eyes
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Grinds teeth
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Sinus problems
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Ringing in ears
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Itchy eyes
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TMJ
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Excessive phlegm
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Poor hearing
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Spots in eyes
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Facial pain
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Phlegm color
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Earaches
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Poor/blurred vision
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Gum problems
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Recurrent sore throat
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Headaches
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Coughing blood
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Asthma/Wheezing
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High Blood Pressure
Difficulty breathing
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Low Blood Pressure
Respiratory and Cardiovascular
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Palpitations
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Tight chest
Thick or thin fluid?
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Fast heart rate
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Chest pain
Color of the phlegm
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Irregular heart beat
When lying down
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Blood clots
Cough (dry/wet?)
Gastrointestinal
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Nausea
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Constipation
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Undigested food in stool
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Bloating
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Itchy anus
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Vomiting
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Laxative use
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Bowel movements:
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Gas
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Burning anus
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Acid reflux
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Black stool
Frequency:
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Hiccups
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Hemorrhoids
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Bad breath
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Bloody stool
Color:brown/black/green/yellow
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Intestinal pain/cramp
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Diarrhea
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Mucus in stool
Texture:soft/firm/pellets
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strong smell of stool
Musculoskeletal
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Neck stiffness/pain
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Lower back pain
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Jaw pain
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weakness
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Shoulder tension/pain
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Knee pain
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Rib pain
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Limited ROM
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Upper back pain
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carpal tunnel/wrist pain
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Joint pain
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Other (describe)
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Skin and Hair
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Rashes
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Eczema
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Change in hair texture
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Hair loss
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Hives
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Psoriasis
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Dandruff
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Scalp tension
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Ulceration
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Acne
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Dry scalp
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Itchy scalp
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Other
Neuropsychological
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Seizures
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Poor memory
Considered/attempted suicide
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Irritability
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Numbness
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Depression
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Easily stressed
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Seeing a therapist
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Tics
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Anxiety
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abuse survivor
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Other
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Genito-urinary
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Pain on urination
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Blood in urine
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Veneral disease
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Increased libido
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Impotence
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Frequent urination
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Unable to hold urine
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Bedwetting
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Decreased libido
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Nocturnal emission
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Urgent urination
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Incomplete urination
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Wakes to urinate
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Kidney stones
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Irregular periods
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Vaginal discharges:
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Vaginal odor / sore
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# of pregnancies
Length of period & cycle
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Painful/cramp periods
Color of the discharge
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Clots
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# of live births
Date of last period
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PMS
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Breast lumps
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Premature births
Gynecology
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Age of menses
Age of menopause