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Patient Intake Form – Traditional Chinese Medicine Acupuncture

Patient Intake Form - Traditional Chinese Medicine Acupuncture

* = Required Field
Personal Information
Name*
First Last
Gender*
Date of Birth*
Date Format: YYYY slash MM slash DD
Address*
Street Address City Province Postal Code
Home Phone*
Mobile Phone
E-mail Address
Occupation*
Length of time in position*
Emergency Contact
Emergency Contact Name*
Emergency Contact Relationship*
Phone*
How did you hear about our clinic?
How did you hear about our clinic?*
Doctor's Name
Name
Social Media
- Facebook
- Instagram
- Twitter
Other
Doctor's Information
Family Physician's Name*
Family Physician's Address*
Street Address City Province Postal Code
Family Physician Phone*
Family Physician Fax
Coverage Details (if applicable)
Primary Coverage
Insurance Company
Plan/Contract #
Certificate/ID #
Policy Holder's Name
Policy Holder's DOB (yyyy/mm/dd)
Date Format: YYYY slash MM slash DD
Relationship to Policy Holder
Health Questionnaire
The 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*
Date Format: 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
Consent
Please 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
Date Format: MM slash DD slash YYYY
Signature
Comments
This field is for validation purposes and should be left unchanged.

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