General Health Registration Form General Health Registration Form Step 1 of 10 10% General Health Registration FormPlease 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 Email example@example.comPhonePlease 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 No 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 No 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) No Details of exercise program:Do you smoke? Yes No 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 No 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 areAre you currently taking any supplements? If yes, please list below:Are you currently taking any herbs? Yes No 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 MedicineChinese 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.1 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 2 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 3 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 4 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) 5 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 6 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 7 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 8 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 HistoryIs 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 pageDiabetesMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleHeart DiseaseMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleHigh Blood PressureMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleKidney DiseaseMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleMultiple BirthsMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleIntellectual DisabilitiesMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleBirth DefectsMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleGenetic/Inherited DiseaseMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleMental IllnessMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleCancerMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleAllergiesMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleDrug AbuseMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleAlcohol AddictionMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleHyper/HypothyroidismMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleLupusMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleBlood DisordersMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleBreast CancerMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleUterine CancerMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleProstate CancerMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleOvarian CancerMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleCystic FibrosisMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UncleSickle Cell DiseaseMotherFatherSisterBrotherPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherMaternal AuntiePaternal AuntieMaternal UncleMaturnal UnclePlease give any other details that are applicable to any of these or other family medical conditions: Musculoskeletal ConditionsIf 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 ConsentPlease read carefully and sign at the endI 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 agreeSignatureName 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.
