Acupuncture Consultation/Consent Form | Aesthetics Forms Portal

Acupuncture Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Surgical History (Please list any operations you have had and include the approximate date of the surgery):

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

What is Acupuncture?

Acupuncture is an ancient Chinese medicine-based approach to treating a variety of conditions by triggering specific points on the skin with needles.

Is Acupuncture safe?

Acupuncture is generally very safe.

Rarely, some people experience mild, short-term side effects such as:

Pain where the needles puncture the skin
Bleeding or bruising where the needles puncture the skin
Drowsiness
Feeling sick
Feeling dizzy or faint
Worsening of pre-existing symptoms

Acupuncture Health Screening

Do you suffer from diabetes? *

Please provide more details:

Have you ever experienced an epileptic seizure? *

Please provide more details:

Have you ever fainted? *

Please provide more details:

Do you have any heart problems? *

Please provide more details:

Do you have a pacemaker or any other electrical implant? *

Please provide more details:

Do you have any problems with your circulation, such as Deep Vein Thrombosis, Pulmonary Embolism or a bleeding or clotting disorder? *

Please provide more details:

Are you receiving, or have you in the past received, anticoagulation therapy? *

Please provide more details:

Do you have, or have you ever suffered from any form of cancer? *

Please provide more details:

Are you aware of any blood borne viruses such as HIV, AIDS, or Hepatitis? *

Please provide more details:

Are you pregnant or trying to conceive? *

Please provide more details:

Do you have a phobia to needles? *

Please provide more details:

Have you ever experienced any adverse effect to previous needling procedures such as acupuncture or injections? *

Please provide more details:

Have you had acupuncture before? *

Please give a brief description of your acupuncture experience(s):

Main Issue

Please answer the following questions based on the main issue you are experiencing.

Have you received a medical diagnosis for the issue? *

Please give a detailed description of the diagnosis you have received: *

Please give a detailed description of your symptoms: *

Have you found anything that relieves the pain? e.g. Ice, Rest, Activity, Massage, Heat etc. *

Have you found anything that aggravates the pain? e.g. Weather, Cold, Heat, Activity, Rest etc. *

Further Issues

Do you have a further issue you wish to be discussed? *

Have you received a medical diagnosis for the issue? *

Please give a detailed description of the diagnosis you have received: *

Please give a detailed description of your symptoms: *

Have you found anything that relieves the pain? e.g. Ice, Rest, Activity, Massage, Heat etc. *

Have you found anything that aggravates the pain? e.g. Weather, Cold, Heat, Activity, Rest etc. *

Lifestyle

Do you smoke? *

How many cigarettes would you smoke in a typical DAY? *

Do you drink alcohol? *

How many drinks would you consume in a typical WEEK? *

One drink is defined as 12 fluid ounces of regular beer (5% alcohol), 5 fluid ounces of wine (12% alcohol), or 1.5 fluid ounces of 80 proof (40% alcohol) distilled spirits.

Do you drink coffee? *

How many cups of coffee would you drink in a typical DAY? *

Do you drink carbonated (fizzy) drinks? *

How many cups of carbonated (fizzy) drink would you drink in a typical DAY? *

Do you take recreational drugs?

How often do you exercise? *

On a scale of 1 to 10 (1 being worst, 10 being best) how would you rate your daily energy level ? *

On average, how many hours do you sleep per night? *

Symptoms

Please check each symptom you have. Leave blank if N/A.

Gan

Xan

Shen

Fei

Pi

Aftercare Advice

Please take a moment to read the aftercare advice specific to your visit.

Be more aware of how you feel. Notice how you feel after acupuncture and mark your own improvement. Notice how long your symptoms seem to have lessened and notice when they creep back up and try to discern why. Was it a sleeping position? Stress from work? Something you ate?

Create lifestyle changes along with your treatment plan. We often ask people to reduce or cut out certain foods that are causing inflammation in the body. Cold, sugary, too spicy, greasy foods should be avoided during a healing process. These are the types of foods that normally are ok in small amounts and once in a while but should not be taken in excess amounts as our culture is prone to. This might also look like adjusting your work and computer set up, taking weekly yoga class, or decreasing your screen time at night.

Hydrate and avoid alcohol. It is important to drink plenty of fluids so that your body can flush out what you don’t need. During acupuncture your body will want to naturally detox and staying hydrated will help with this process. Avoid alcohol for the next 24 hours. As your body is detoxing you don’t want to give anything additional to your liver to flush out. If you feel residual soreness or tiredness -refrain from alcohol until it subsides.

Take it easy and rest. It may have seemed like you just laid there during treatment but internally, your body is doing work. Healing requires your energy, which means you should not push yourself afterwards because it will ask your energy to work harder when it should be in a repair and heal mode. No working out until the next day. If you feel soreness after the treatment, up your water intake and wait until the soreness subsides before resuming workouts.

Keep yourself warm. Maintaining the environment of your body is important. After acupuncture, massage, cupping and/or any other type of body work, you should not take a shower or go swimming for 12-24 hours. This allows the treatment to remain in the body undisturbed.

Come in for more frequent treatments at first and follow up according to the treatment plan given to you. Acupuncture is natural and it does not add any substances into your body but it is still medicine. All medicine should be administered over time. Like going to the gym you can’t expect desired results after only one or two visits. Give your body the time it needs to heal.

Meditate. Being able to still and calm the mind will aid your ability to navigate stressful situations with more ease, which ultimately aids the healing process.

Pay attention to some of the things about your body and lifestyle you might not have paid attention to before. Sometimes we ask people how their sleep or digestion is and they realize it is not as great as it should be.

Begin to think preventatively. Start noticing and being more aware of your body’s sensitivities and tendencies. This will teach you how to identify when something about your health is out of balance. Coming in for a series of acupuncture visits when you notice things are off, during seasonal changes or when you know you’ll be going through a stressful period will help you get ahead of the game. Learning to take action before your health condition becomes more severe, longer standing or difficult will save you time and money in the long run!

BREATHE better. Yes, deep breaths. Set a timer for every hour to pause and take 3 really deep breaths. This is very easy to accomplish! Breathing helps everything circulate and move really well in the body which makes you feel immediately good. It is also totally free!

Chinese Medicine is a way of life. There is a lot to reconcile within ourselves because we live in the modern world that draws us further from our natural selves. Simply being aware of this can help you to make small changes to incorporate a little more nature to your daily life.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me on this form.

Consent

I confirm I have answered the questions honestly and to the best of my knowledge. I know of no reason that I should not have acupuncture treatment. By my electronic signature below, I acknowledge that I have read and fully understand all the information detailed above. *

Tap or click on the signature above to sign