Patient Intake Form – Traditional Chinese Medicine Acupuncture Patient Intake Form - Traditional Chinese Medicine Acupuncture * = Required FieldPersonal InformationName* First Last Gender*GenderFemaleMaleOtherDate of Birth* YYYY slash MM slash DD Address* Street Address City Province *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone*Mobile PhoneE-mail Address Occupation* Length of time in position* Emergency ContactEmergency Contact Name* Emergency Contact Relationship* Phone*How did you hear about our clinic?How did you hear about our clinic?*How did you hear about our clinic? (Please select one)Walk-inDoctorFriend or FamilyGoogleWebsiteSocial Media (Facebook, Instagram, etc.)OtherDoctor's Name Name Social Media Facebook Instagram Twitter Other Doctor's InformationFamily Physician's Name* Family Physician's Address* Street Address City Province *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Family Physician Phone*Family Physician FaxCoverage Details (if applicable)Primary CoverageInsurance Company Plan/Contract # Certificate/ID # Policy Holder's Name Policy Holder's DOB (yyyy/mm/dd) YYYY slash MM slash DD Relationship to Policy Holder 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. 2. 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 Dis-coordination Nervousness Recent Weight Loss/Gain Numbness/Pain in Arms and/or Legs None of the above Cardiovascular* High Blood Pressure Low Blood Pressure Chronic Congestive Heart Failure Heart Attack Phlebitis Stroke / CVA / TIA High Cholesterol Swelling of Ankles Poor Circulation Irregular Heartbeat Shortness of Breath Pain Over Heart None of the Above Respiratory* Chronic Cough Shortness of Breath Bronchitis Wheezing Emphysema Spitting up Phlegm Chest Pain Difficulty Breathing None of the above Muscle and Joint* Stiff Neck Backache Swollen Joints Painful Tailbone Pain in Shoulder Area Hernia Spinal Curvature Faulty Posture Arthritis Foot Trouble None of the above Genitourinary System* Frequent/Painful Urination Blood in Urine or Stool Mucus in Stool Kidney Infections Kidney Stones Bladder Infections Incontinence None of the above Skin* Skin Conditions or Rashes Itching Bruise Easily Dryness Boils Varicose Veins Sensitive Skin Hives or Allergies None of the above 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 None of the above 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 None of the above Women Only* Cramps Backache Previous Miscarriage Irregular Cycle Vaginal Discharge Lumps in Breast Menopausal Symptoms Painful Menstruation Excessive Flow Hot Flashes Hysterectomy Pregnant None of the above Due Date* MM slash DD slash YYYY 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 None of the above 2. Please give a list of all surgeries, past injuries or major dental work you have had:4. Please provide a list of your current medications and conditions it treats:6. Do you have an internal pins, wires, artificial joints or special equipment?* Yes No ConsentPlease read the following carefully and fully: Palermo Physiotherapy and Wellness Centre is a multidisciplinary health care provider where the practitioners work in conjunction to provide you, the patient, thorough care and treatment. All staff members are required to sign a confidentiality form with regards to your personal information and are trained in appropriate use and protection of your information. All handling of your information is compliant with existing college guidelines and provincial and federal legislation. Our clinic uses your information to ensure you receive the best care.E-mail I give permission for Palermo Physiotherapy and 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* 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. Cancellation of Appointment* Palermo Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $25.00 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 Patient Name* First Last Date MM slash DD slash YYYY SignatureNameThis field is for validation purposes and should be left unchanged.
