Acupuncture Bioregulatory Medicine Initial Consult
SURNAME:_________________________CHRISTIAN NAMES:______________________________ TODAY’S DATE___________
ADDRESS:_________________________________________________________________________POST CODE_____________.
PHONE____________MOBILE PH__________________EMAIL_______________________________DATE OF BIRTH________
Male/Female
Married/Single/Other……………. CHILDREN: Y/N Ages
PRESENT OCCUPATION:
HEALTH FUND
Girls/ Boys?
PREVIOUS OCCUPATIONS:
HOBBIES/RECREATION ACTIVITIES
Do you have any known allergies or sensitivities?
PRIVATE
GP Name
What would you most like to achieve through your work at Qimax?
Main Symptoms: Please list in order of importance which symptoms are of concern to you.
To what extent do these conditions interfere with your daily activities (work, sleep, socializing, family, etc.)?
What other treatments have you tried for these problems and how successful have they been?
Are you experiencing pain or discomfort in your body? Y / N
If yes please indicate on the diagram below the location of the discomfort using the symbol that best describes the feeling:
Mark the area of concern/pain:
XXXX- sharp/stabbing
PPPP- pins & needles
DDDD – dull/aching
NNNN- numbness
Severity of pain/ discomfort please circle.
0 1 2 3 4 5 6 7 8 9 10 [0 = no pain 10 – excruciating pain]
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HEALTH QUESTIONAIRE – Circle where appropriate.
Have you had any major accidents?
Have you had any surgery?
Have you had any major illness?
Diabetes/ High cholesterol / High blood pressure/ Low blood pressure/ Coronary artery disease / Siezures / Thyroid issues/
Cancer…………………………../ HIV / Hepatitis/ Hep C positive/ Other...
Have you had Measles/ Mumps /Chicken Pox/ Rubella/ Other childhood diseases?
Have you been immunized? Polio/ Tetanus/ Triple Antigen/ Whooping cough/ Rubella/ Measles/mumps/ Meningococca/ Influenza
Vaccine/ HPV Gardasil
Are you currently under medical or psychological treatment?
Please list current medications and health supplements that you are taking?
Have you previously taken Antibiotics/ Cortisone/ Prednisolone/ Oral, injectable or inplant contraception?
Lifestyle:
Have you had exposure to known toxins?..................................
Do you smoke Y/N How many per day? Quit Y/N When?
Recreational drugs? Current ? Y/N …………Past ? Y/N……..
Alcohol use? Y/N Current drinks per day………………..per week………...What do you drink?............
Have you ever had a problem with dependency on other drugs? Y/N If yes which and when?
Nutrition: : Do you follow a special diet? Y/N If yes describe the diet?
What do you eat on a “typical” day?
BreakfastLunchDinnerSnacksFood you tend to crave –
Foods you dislike –
How much water do you drink per day?........... How much tea?
Coffee?
Soft drinks?
Wellness: In the past year, how many days have been significantly affected by your health?
How many days did you feel generally poor?
How many times were you in the hospital?
Exercise: Hours per week: ______ Activities: _______________________________________
Sleep: How many hours of sleep do you usually get per night during the week? _____________
Do you awake rested? Y/N Do you feel you sleep well at night? Y/N Difficulty getting to sleep?Y/N Wake at night?Y/N Time?
Emotional: Who would you describe as your source of primary social support? (relationship to you)__________________
Do you have any other neurological or psychological problem? Y/N Have you been treated for or suffered from emotional issues?Y/N
Family:
Please list any major family illnesses. (ie/ cancer/stroke/ heart problems/ high blood pressure/ emotion problems/ asthma// immune
problems/genetic etc)
For Women:
Are you pregnant now? Y/N/Unsure Date of last period_________Number of Pregnancies__ Miscarriages ___Abortions ____
Age: First period _____ Menopause (if applicable) _____
Date: Last Pap Smear _ /__Last Mammogram _ / _ Any History of an Abnormal Pap Smear? [ ] Yes [ ] No
Details ______
Is your menses cycle regular? Y/N Average number of days of flow ______ Flow is: Normal/ Heavy/ Light
Blood colour: Normal /Dark/ Purple/blue tinge/ Light Brown// Brown/Watery
Blood clots? Y/N,
Colour of clots : dark / purple or blue tinge
Pain Yes/No If yes -.Where? Pelvis /Back/Thighs/ other. When? Before/Early/ After period/Mid cycle
PMS - Cramps/ Breast tenderness/ Vaginal discharge/ Irritable moody//Pain with intercourse/ Libido problems
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HEALTH CHECKLIST: MARK ALL THAT APPLY WITH X
GENERAL
Past
Current
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SKIN & HAIR
Past
Current
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HECK & NECK
Past
Current
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Condition
Past
Poor appetite
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Excessive appetite [ ]
Insomnia
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Fatigue
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Fevers
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Night sweats
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Sweat easily
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Chills
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Localized weakness[ ]
Poor coordination [ ]
Bleed/bruise easily [ ]
Catch cold easily [ ]
Change in appetite
Strong thirst
Other: _________ Past
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Condition
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Rashes
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Hives
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Itching`
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Eczema/dermatitis [ ]
Pimples/acne
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Dryness
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Tumors, lumps
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Condition
Past
Dizziness
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Fainting
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Neck stiffness
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Enlarged glands [ ]
Headaches
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Concussions
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Other: __________ [ ]
EARS
Past
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Current
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Condition
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Infection
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Ringing
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Decreased hearing [ ]
Other: __________ [ ]
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EYES
Past
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Current
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Condition
Blurred vision
Visual changes
Poor night vision
Spots
Cataracts
Glasses / contacts
Eye inflammation
Other: _________
CARDIOVASCULAR
Current Condition
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High blood pressure
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Low blood pressure
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Blood clots
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Palpitations
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Phlebitis
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Chest pain
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Irregular heart beat
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Cold hands / feet
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Fainting
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Difficult breathing
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Swelling of hands / feet
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Other: _____________
Current
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GENITO-URINARY
Past
Current
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NOSE, THROAT, MOUTH
Past
Current Condition
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Nose bleeds
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Sinus infections
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Hay feve/ allergies
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Recurring sore throats
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Difficulty swallowing
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Loss of taste or smell
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Other
MALE
Past
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RESPIRATORY
Condition
Asthma
Bronchitis
Frequent colds
Chronic obstructive
Pulmonary disease
Pneumonia
Cough
Coughing blood
Production of phlegm
Other: ______________
GASTRO-INTESTINAL
Condition
Nausea
Vomiting
Diarrhea
Belching
Blood in stools/black
Stools
Bad breath
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Rectal pain
Hemorrhoids
Constipation
Pain or cramps
Indigestion
Gall bladder disorder
Gas
Other: ______________
Condition
Kidney stones
Pain or urination
Frequent urination
Blood in urine
Urgency to urinate
Unable to hold urine
Other: ______________
Current
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FEMALE
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NEUROLOGICAL
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PSYCHOLOGICAL
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Past
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Condition
Frequent urinary tract infections
Frequent vaginal infections
Pain / itching of genitalia
Genital lesions / discharge
Pelvic inflammatory disease
Abnormal pap smear
Irregular menstrual periods
Painful menstrual periods
Premenstrual syndrome
Abnormal bleeding
Menopausal syndrome
Breast lumps
Hot flashes
Menopausal syndrome
Other: _____________
Condition
Seizures
Tremors
Numbness/tingling of limbs
Concussion
Pain/ headaches
Paralysis
Other: __________________
Condition
Depression
Anxiety / stress
Irritability
Treated for emotional or
Psychological problems
Other: __________________
INFECTION SCREENING
Current Condition
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HIV
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TB
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Hepatitis
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Gonorrhea
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Chlamydia
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Syphilis
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Genital warts
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Herpes: oral
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Herpes: genital
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MUSCULAR-SKELETAL
Past
Current Condition
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Stiff neck / shoulders
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Low back pain
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Back pain
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Muscle spasm, twitching, cramps
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Sore, cold or weak knees
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Joint pain or swelling
Condition
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Other_______________
Pain / itching genitalia
Genital lesions/ discharge
Impotence / erectile issues
Lumps in testicles
Cold or Numb genitals
Other………………..
Any other relevant information :
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Acupuncture/Biomesotherapy/Biopuncture Consent Form
GIVEN NAME:
_______________________SURNAME:
D.O.B: ___________________
SEX:
M
F
___________________________________
PRACTITIONER: ___________________
A. CONDITION AND PROCEDURE
The Practitioner has explained that I have a condition, which may respond to: (circle)
▪ Biomesotherapy
▪ Cupping ▪Scraping
▪ Acupuncture
▪ Electro-Acupuncture
▪ Moxibustion
* Heat Lamp
▪ Tui-Na
* PStim
Other_____________
These procedures may assist you with your health care, however there are some risks involved with any sort of treatment.
The above procedures may involve the insertion of sterile needles, cupping techniques which typically leave bruising, biomesotherapy - saline
solution will be inserted into important trigger points, pain points or acupuncture points, the application of heat near the skin via moxibustion or heat
lamp and other methods that may cause the following:
B. RISKS OF THE PROCEDURE
Acupuncture/ Biomesotherapy/PStim
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As with any procedure that punctures the skin, infection is a risk (however, infection control procedures substantially reduce such risks).
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The skin around the injection site can remain red and itchy until the next day.
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Bruising of the area may occur.
Cupping, Scraping (Gua Sha), Tui-Na (Chinese massage)
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Bruising of the area may occur.
Moxibustion/ Heat lamp
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The application of heat to the skin carries the risk of minor burning.
Electro Acupuncture/PStim
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There is no risk of electrocution although occasional uncomfortable sensations may be experienced
General – may apply to all proceedures

Occasionally slight to moderate discomfort may be experienced, your practitioner will aim to minimize this discomfort

Rarely a procedure may aggravate your condition, but this is uncommon.
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It is especially important to tell us if you bruise easily or have a bleeding disorder.
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It is common to feel relaxed or sleepy after some of these treatments, so avoid getting of the treatment table too quickly. Give yourself time
to adjust.
C.
Significant risks
The practitioner has explained any significant risks and problems specific to me, and the likely outcomes or non-outcomes.
D. I acknowledge that:
The practitioner has explained the proposed procedure. I understand the risks, including the risks that are specific to me,
I was able to ask questions and raise concerns with the practitioner about the procedure and its risks, and my options. My questions and concerns
have been discussed and answered to my satisfaction.
On the basis of the above statements I freely:
REQUEST AND CONSENT TO THE PROCEEDURE/S CIRCLED ABOVE
Name of Patient_________________________Substitute decision maker and relationaship_____________________________
______________________________________
Signature
________________________
Date
*Substitue Decision Maker If: the patient is not an adult (over 18) and/or unable to give consent, an authorised decision-maker must give consent on
the patients behalf.
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Practitioner Initial Enquiry: Name
DOB
Date
Presenting Complaint –
History of PC-
Treatments
Side effects
Investigations
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Past History:
Medical
Surgical
Family Hx
Social
Childhood/immunisation/medications/birth trauma/other trauma
Musculo skeletal
Where
Pain ache sharp dull fixed moving radiating
How long
Aggravations
Ameliorations
CNS
Dizziness
Headaches where
numbness
tingling
how long
OENT
Eyes- Liv- colour
tired
Tinitus= K
Nose
sinus - Lu Sp
CVS
Chest pain
sensitive
puffy
hayfever
Hypertension
RESP
SOB
Asthma
Recurrent colds/ infections
Smoke:
How many?
GIT
Digestion St
Diarrhoea Sp
Palpitations
Exceretions mucous colour
Quit?
When?
burning, vomiting
Circulation
viscosity
bloating
Constipation
GNU
Frequency
Burning
Menstruation Kids Liv Gb Ht Bl
LMP
Regularity
length
Pain
when
Irritability
Mood swings
Ameliorations
Aggravations
Fertlity /libido
Colour
Menopause
flow
rash
itch
Amt
Menarche
colour
where
Breast tenderness
clots
how long
History
Endo
Energy levels am/pm
1 2 3 4 5 6 7 8 9 10
Stress levels
home 1 2 3 4 5 6 7 8 9 10
Sleeping
getting to sleep
Integumentary dry skin
time
Afternoon low
Work 1 2 3 4 5 6 7 8 9 10
wakes
other sweat/ night/ not sweat
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F
Facial signs -
Aggravations/Ameliorations
Worse in the Morning/ Afternoon/ Evening/ Nocte
Better for cold/heat?
Outside/Inside
Better /Worse for movement?
Better/ Worse for pressure?
Rain/Seaside
Mineral/ Tissue salt indications -
TCM
XS
Cold
Heat
Wind
DEF
Damp Phlegm X
Pain
3 Lu/5LI
7St /9 Sp
11 t/13Si
15Ub/17K
19PC/21SJ
23GB/ 1Lv
Ren/Du
Extra
Tongue:
Body
Pulses
Rt
Lt
Coat
L
H
Other
Sp
Li
KYg
KYn
Inspection and observation:
Int/Ext
Hot/Cold
Channels
TCM Diagnosis:
Yin/Yang
Def/XS
Organs
Blood/Qi/BodyFluids
Five elements
Homotoxicology:
DET: Ecto,/ Meso/ Endo
Excretion/Inflammation/Deposition/Impregnation/Degeneration/Dedifferentiation
Symptomatic Rx
Drainage git /Detox cellular /lymphatic
Immune modulation/ regulation
Cellular activation/organ regeneration
Treatment Plan:
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