Traditional Chinese Medicine Acupuncture Intake Form Personal InformationName(Required) First Last Address(Required) Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Sex(Required) Male Female Other Home Phone(Required)Cell PhoneDate of Birth(Required) Year Month Day Email Address(Required) Occupation(Required) Length of Time at Job Emergency Contact(Required) Phone(Required)Relationship(Required) Doctor's InformationFamily Physician(Required) Address(Required) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)FaxEmail Coverage Details (if applicable)Primary CoverageInsurance Company Plan/Contract # Certificate/ID # Policy Holder's Name Policy Holder's DOB (yyyy/mm/dd) Year Month Day How did you hear about our clinic?(Required) Walk-in Google Friend/Family Doctor Social Media (Facebook, Instagram) Marketing Material (Brochure, Flayer, Business Card) Already our Patient Other Health QuestionnaireThe information requested below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided will be kept confidentially unless allowed or required by law. Your written permission will be required to release any information. 1. Do you presently have or ever had any of the following? Check all that apply:General Symptoms Headaches/Migraines Fever Chills Sweating Memory Loss Dizziness/Light Headiness Fainting Stress/Depression Discoordination Nervousness Recent Weight Loss/Gain Numbness/Pain in Arms and/or Legs Cardiovascular High Blood Pressure Low Blood Pressure Chronic Congestive Heart Failure Heart Attack Phlebitis / Varicose Veins Stroke / CVA / TIA Pacemaker or Similar Device Heart Disease High Cholesterol Swelling of Ankles Poor Circulation Irregular Heartbeat Shortness of Breath Pain Over Heart Respiratory Chronic Cough Shortness of Breath Bronchitis Wheezing Emphysema Spitting Up Phlegm Chest Pain Difficulty Breathing Muscle and Joint Stiff Neck Backache Swollen Joints Painful Tailbone Pain in Shoulder Area Hernia Spinal Curvature Faulty Posture Arthritis Foot Trouble Genitourinary System Frequent/Painful Urination Blood in Urine or Stool Mucus in Stool Kidney Infection Kidney Stone Bladder Infection Incontinence Skin Skin Conditions/Rashes Itching Bruise Easily Dryness Boils Varicose Veins Sensitive Skin Hives or Allergies Ears, Eyes, Nose, Throat Hearing Loss Vision Problems Glaucoma Ringing in Ear(s) Crossed Eyes Eye Pain Deafness Earache Ear Discharge Nose Bleeds Nasal Obstruction Sore Throat Hoarseness Hay Fever Asthma Dental Decay Gum Trouble Frequent Colds Enlarged Thyroid Tonsillitis Sinus Infection Nasal Drainage Enlarged Glands Gastrointestinal Poor Appetite Distress from Greasy Foods Excessive Hunger/Thirst Belching or Gas Nausea Vomiting Burning in Stomach Pain Over Stomach Heartburn Constipation/Diarrhea Colon Trouble Liver Trouble Hepatitis Gall Bladder Ulcers Colitis/Crohn’s Hemorrhoids Hypoglycemia Hiatal Hernia Metallic Taste Women Cramps Backache Previous Miscarriage Irregular Cycle Vaginal Discharge Lumps in Breast Menopausal Symptoms Pregnant Painful Menstruation Excessive Flow Hot Flashes Hysterectomy Have you had any of the following? Appendicitis Malaria Chicken Pox Alcoholism Osteoporosis Diabetes Venereal Infection Cold Sores Whooping Cough Cancer Epilepsy Multiple Sclerosis Anemia Heart Disease Tuberculosis Pneumonia Measles Goiter Eczema Mental Illness Mumps Influenza Gout Polio Pleurisy Pneumatic Fever Arthritis Rubella Parkinson’s Disease HIV/AIDS 2. Are you currently receiving treatment from another health care professional? If yes, for what?3. Please give a list of all surgeries, past injuries, or major dental work you have had:4. Please provide a list of any allergies, your current medications, and conditions it treats:6. Do you have an internal pins, wires, artificial joints, or special equipment?(Required) Yes No ConsentE-mail(Required) I give permission for Palermo + Physiotherapy & Wellness Centre to use the email provided to send reminder emails of scheduled appointments, for paperless billing and for information regarding changes in clinics offerings. Payment Information(Required) I understand that payments for services at Palermo + Physiotherapy and Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third-party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment.Acupuncture Fees:Initial Assessment: $145.00Treatment: $105.00 Cancellation of Appointment(Required) Palermo + Physiotherapy & Wellness Centre requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $45.00 cancellation charge may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment. Consent to Collect, Use and Disclose Personal Health Information(Required) I consent for Palermo + Physiotherapy & Wellness Centre to collect, use and disclose my personal health information for the purpose of providing traditional Chinese medicine or acupuncture to me and for the related purposes set out in Palermo Plus Physiotherapy and Wellness Centre’s Written Privacy Statement.The personal health information that may be collected, used, or disclosed by the Clinic may include the following, among other things:my birthdate and contact informationmy health history and family health historymy health statusthe health care I receive (including identifying my health care provider(s)the identification of my substitute decision-maker, if anyinsurance or billing information relating to health careI understand that there may be situations in which practitioners at Palermo Plus Physiotherapy and Wellness Centre will have to collect, use or disclose personal health information without my consent, but that they will only do this if permitted by law.How My Information Will Be UsedI understand that my personal health information may be collected, used or disclosed for the following reasons:To provide me with traditional Chinese medicine or acupuncture servicesTo obtain payment for services providedTo assist insurance companies with insurance claims verificationTo seek advice for potential treatment optionsTo provide or arrange health care in cases of emergenciesTo fulfill any obligations as mandated by lawPatient Access to InformationI understand that my personal health information is available to me for my review except in limited circumstances as permitted by law. I also understand that I can ask to have my personal health information corrected if I believe there is a mistake in the records, with some exceptions.AcknowledgmentI allow Palermo Plus Physiotherapy and Wellness Centre to collect, use and disclose my personal health information as outlined above. I understand that I can access my personal health information with some limited exceptions.I understand that I am not required to sign this form and that I can withdraw my consent at any time by contacting Palermo Plus Physiotherapy and Wellness Centre, but it may directly affect the services I can receive. My personal health information may still be collected, used, or disclosed if permitted by law. Do Not Consent Additional Comments or RestrictionsPatient (or Guardian) Name:(Required) First Last Patient (or Guardian) Signature(Required)Date(Required) Year Month Day NameThis field is for validation purposes and should be left unchanged.
