General Health Registration Form

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General Health Registration Form

Please fill in the form below (allow up to 15 minutes and please use as much detail as possible as it will help us to provide a better experience and more rapid outcome for you, and you will get more out of each treatment, and more bang for your buck!:))

Name

First Name Last Name

example@example.com

Phone

Please enter a valid phone number.

Address

Street Address Street Address Line 2 City State/Province ZIP / Postal Code

Do you have private health insurance?

Yes

Who is your Health Insurance provider?

How did you hear about Ford Acupuncture?

One of our current patients

Google Search

Google Maps

Google Ads

Word of Mouth

Walking Past

Flyer

Facebook

Instagram

Other

What did you hear about Ford Acupuncture?

Main Reason(s) you are coming in to Ford Acupuncture?

How long has this/these been a problem for you?

Have you been given a professional diagnosis for this problem(s)? If so, what , and by whom?

What kind of treatments have you tried for this problem(s) and which are you persisting with and why?

Have you had Acupuncture or East Asian Medicine before?

Yes

Where did you get Acupuncture (which business/acupuncturist)?

If yes, what was your experience? What did you like about it? What did you NOT like about it?

What is your expectation or gaol from attending Ford Acupuncture?

On a scale of 1-10, how committed are you to correcting the problem(s) that are affecting your health?

Please enter a number from 1 to 10.

1=not committed, 10=will do anything to get better

What is your occupation?

How many hours a week are you working?

What do you do for fun? Hobbies/sport/recreational activities?

Do you have a regular exercise program?

Yes(please provide details below)

Details of exercise program:

Do you smoke?

Yes

Occasionally

If you smoke, how many cigarettes a day?

Do you drink alcohol? How regularly? What type (beer, red wine, white wine, spirits with mixers or straight spirits)?

Do you drink coffee? If yes, how many per day?

1 Coffee

2 Coffees

3 Coffees

4+ Coffees

I dont drink Coffee

Please list what sort of tea you drink:

Please detail if you drink sports drinks or energy drinks or soft drinks below include quantity and which ones you drink:

How much water do you drink every day?

Is your water?

Tap water

Filtered water

Type option bottled water

Drunk from plastic bottles

Drunk from glass container

Sparkling water

Have you every taken recreational drugs?

Yes

Are you allergic to any medications that you are aware of?

Do you suffer from any allergies?

Do you currently take any medications? Please list below if you are

Are you currently taking any supplements? If yes, please list below:

Are you currently taking any herbs?

Yes

Please list herbs/herbal formula as well as the reason for taking them:

please list any previous surgeries you have undergone including dates and surgical outcomes/complications:

Medical conditions past or present (please select any that apply to you)

Migraine

German Measles (Rubella)

Prolonged Dizziness

Eczema

Psoriasis

Acne

Herpes Zoster

Glasses/Contact Lenses

Thyroid Issues

Pneumonia

Tuburculosis

Asthma

Bronchitis

Other Lung Conditions

Heart Attack

Heart Murmer

Rheumatic Fever

Other Heart Condition

High Blood Pressure

Gastric/Duodenal Ulcers

Gastric Reflux

Hepatitis

Intestinal Bleeding

Bleeding Tendency (Bruise Easily)

Problems with Anesthesia

Diabetes Type 1

Diabetes Type 2

Kidney Stones

Kidney Infection

Other Kidney Disorders

Bladder Infection

Rheumatoid Arthritis

Other Forms of Arthritis

Lupus Erythematosus

Paralysis

Neurological Disorders

Thrombophlebitis

Varicose Veins

Obesity

Stroke

Other

Other (please list):

Chinese Medicine

Chinese Medicine Please ensure you fill every question out in this section as this will greatly assist with your acupuncture treatment and treatment outcome. Please select all of the following symptoms that you have experienced in the past 6 months.

Lower back weakness, soreness or pain

Knee problems

Ringing in the ears or dizziness

Prematurely Grey hair

Dark circles under or around eyes

Night sweats or hot at night

Prone to hot flushes

Experience fear in your daily life

Lower back pain premenstrually

Cold feet and hands

Typically feel colder than those around you

Low libido/sex drive

Wake up frequently at night to urinate

Frequent urination and this urine is light in colour

Woken by loose bowels

Feel tired after ejaculation/sex

Often feel fatigued

Energy is lower after eating

Often feel bloated after eating

crave sweet food

Often have digestive issues or abdominal pain

Nose often feels cold

Heaviness or foggy feely in your head

Bruise easily

poor circulation

Prone to worry

Been diagnosed with low blood pressure

Sweat a lot without exerting yourself

Often feel lightheaded or dizzy or have visual changes after standing up

Often sick or have allergies

Haemorrhoids, polyps or prolapse

History of Anaemia

Dry, flaky skin

Psoriasis or eczema

Chapped lips

Brittle fingernails or toenails

Hair loss on your head

Diminished night time vision

Experience dizziness or lightheadedness

Shortness of breath

Heart palpitations (feel your heart beating in you chest)

Periodic numbness

Varicose veins or spider veins

Lower abdominal pain or tenderness on palpation (when touched)

Dark spots in vision

Stabbing, fixed pain that you can pinpoint the location of

Prone to emotional depression

Prone to anger or quick to fire or rage

History of being diagnosed with high prolactin levels

Difficulty falling asleep at night

Heartburn or wake up with a bitter taste in your mouth

Unexplained pain under your ribs, chest or abdominal region

Frequently sighing

Regular belching or passing of gas regularly

Tight neck and shoulders

Stressed about work

Stressed at home

Highly stressed

Headaches at the top of your head

Headaches around temples

Rapid pulse rate

Often have a dry mouth and throat

Thirst for cold drinks most of the time

Often feel warmer than those around you

Wake up sweating or have hot flushes

Break outs with red acne

Face and eyes turn red easily

Acid regurgitation

Experience constipation

Red skin rashes

Concentrated (yellow) urine

Smelly urine

Restless leg syndrome

Feel tired and sluggish after a meal

Cystic or pustular acne

Urgent, bright or mould smelling stools (poo)

Fibrocystic breasts

Joints that ache, especially with movements

Overweight

Often have damp, sticky (stick to the toilet bowl or need to use lots of toilet paper), unformed stools

Crave sweet food

Family Medical History

Is there history of any of the following conditions in your family?

Please select the closest in relation when selecting the family memeber that has the listed condition. Any extra family members with these condtions can be mentioned in the details box at the bottom of the page

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Multiple Births

Intellectual Disabilities

Birth Defects

Genetic/Inherited Disease

Mental Illness

Cancer

Allergies

Drug Abuse

Alcohol Addiction

Hyper/Hypothyroidism

Lupus

Blood Disorders

Breast Cancer

Uterine Cancer

Prostate Cancer

Ovarian Cancer

Cystic Fibrosis

Sickle Cell Disease

Please give any other details that are applicable to any of these or other family medical conditions:

Musculoskeletal Conditions

If you are seeking treatment for musculoskeletal issues please fill out the following questions, if not please move forward...you're almost finished 🙂

Where in your body is your pain or discomfort located?

When did this start?

What is the cause of this (only if known)

Can you best describe what discomfort you feel?

Is this a recurring problem?

Does the pain Stabbing or Aching? Or does it alternate between these?

Does the pain move or is it in a fixed location?

What makes the pain BETTER? Movement? Heat? Cold? Pressure?

What makes the pain WORSE? Movement? Heat? Cold? Pressure?

Have you sought help for this elsewhere? If so, by who and what modality? What was your experience and outcome?

Is your condition worse with stress?

On a scale of 1-10 what do you rate the pain on a good day? 10= excruciating, debilitating, can't move or get out of bed 1=occasionally I'll feel it but doesn't bother me

On a scale of 1-10 what do you rate your pain on a bad day? 10= excruciating, debilitating, can't move or get out of bed 1=occasionally I'll feel it but doesn't bother me

Do you experience any loss of function or mobility due to your pain?

Informed Consent

Please read carefully and sign at the end

I have read and fully understand all of the above. I have answered all the questions accurately and truthfully to the best of my knowledge and will discuss any further questions and concerns that I may have with my practitioner at my initial consultation. *(Required)

Yes I agree

Signature

Name

First Name Last Name

I am unable to electronically sign and will sign the Informed Consent Form at my initial consultation:

I agree to the privacy policy.