Traditional Chinese Medicine Intake Form

Overview

Title:

First Name *

Last Name *

Birth date: *

Goals & experience:

Goals/aims from the consult: *

Have you seen an TCM practitioner or received acupuncture before? *

Yes No

Lifestyle factors

Employment *

Occupation

Average working hours per week

0-15 hours 15-30 hours 30-40 hours 40+ hours

Physical Activities *Hobbies, interests, exercise. If exercise, include details about type, how often and for how long.

Recent life events:E.g. change of job, move house, relationship or family changes & additions, major health event to self or family member.

Main Complaint

In this section please complete details ONLY about your main complaint/issue. This is generally for only one part of your body. There is a section later in the form for other complaints (if present).

When & how did your symptoms/issue begin? *If your complaint occurred acutely, provide details about the date and how it occured, e.g. January 2022, after cutting firewood. If your complaint occurred gradually, specify a rough estimate of how long you've had the problem and what may have contributed to it starting, e.g. gradual onset over last 5 years from sitting at work.

Since your complaint/issue began is it? *

ImprovingWorseningAbout the same

Describe the nature of your complaint: *E.g. swollen feet, cramps, body temperature issues, digestive issues - bloating, reflux etc.

My complaint is: *

ConstantComes and goesWorse in morningsWorse in afternoon/evenings

What factors aggravate your issue/complaint? *e.g. activity levels, rest, food, stress, sleep

What helps to relieve your issue/complaint? *e.g. alterations to the following activity levels, food, stress, sleep

Are there any other factors to note about your complaint? *

Other Complaints

If you have other complaints, provide as much relevant detail about them as you can.

Medical information

Medical conditions (current & past): *Provide details about the date you were diagnosed and if and if the condition still affects you. E.g. type 2 diabetes since 2014, managed medically, glucose levels stable.

Allergies *

Medications/supplements *If possible, provide details about dosage.

Surgeries *Provide details about the date, body region and if you have fully recovered. E.g. right knee replacement 2018, still stiff when bending. Gallbladder removal 2015, no ongoing issues.

Family medical history *Provide details regarding who is affected and what condition, e.g. heart disease, high blood pressure, stroke, certain cancers, and type 2 diabetes.

Do you smoke? *

Yes No In the past

Number of cigarettes per day

Less than 55 to 15More than 15

Female patients only section

Menstrual Cycle

RegularIrregularAbsent

Age of first period:

How many days is your current cycle?

Pregnancy

No previous pregnancyPast pregnancyCurrently pregnant 1st trimester (0-12 weeks)Current 2nd trimester (13-27 weeks)Current 3rd trimester (28-40 weeks)

Number of pregnancies:

To how many children have you given birth?

Please outline your experience with pregnancy (current and/or past):Please include comments about fluid retention, heart or blood pressure issues, DVT, anemia, preeclampsia

Consent to Traditional Chinese Herbal Medicine and Acupuncture treatment

Please tick if you understand and accept the following:

Personal details need to be provided for osteopathic consults. Our privacy policy outlines what information we collect & your rights regarding the information that you supply to us. This policy can be read via our website http://promhealth.au/policies. It is also available at any time in the future upon request. *

The consult may involve partial disrobing (undressing). A gown will be provided upon request.
*

Treatment may involve some pain or discomfort. Your practitioner will try to minimise your pain and discomfort throughout the consult.
*

Constant and clear communication between myself and my practitioner is a key element in receiving care. *

You can always say no to any part of a Traditional Chinese Medicine consult. Please tell us if this is the case. *

I understand & accept the risks associated with Traditional Chinese Medicine & Acupuncture consults as outlined below. *

1. Traditional Chinese Medicine is generally considered a safe form of health service.

2. However, we need to make you are aware of the risks associated with a TCM consult before deciding to receive it.

3. Traditional Chinese Medcine practitioners are trained health-professionals. We use our best clinical judgement to limit foreseeable risk to patients from treatment and openly discuss these risks.

4. There is risk associated with the examination, treatment & management we provide. Risk is relative to your individual circumstances & your particular consult.

A Traditional Chinese Medicine treatment may include but is not limited to:

Acupunture, Electroacupuncture, Moxibustion, Cupping, Gua-sha, Infrared Heat treatment, Tui-Na (Chinese massage), Chinese or Western herbal medicine and nutritional counselling.

Each of these treatment modalities have different side effects or risks. We will list these below:

1. Acupuncture:

Involves the use of fine stainless steel needles inserted into specific points. Practitioners are trained in sterlisation and infection control procedures.

Common side effects during and after an Acupuncture treatment include , but is not limited to:

Temporary aggravation of symptoms.
Minor swelling, bruising or bleeding at site of needle insertion.
Numbness or tingling.
Dizziness or fainting, nausea.

Serious risks to treatment are incredibly rare. There is a lack of evidence to conclude figures. Despite the rarity, these risks are believed to exist. Therefore, we need to make you aware of them.

They include:

Infections.
Pneumothorax (punctured lung).

2. Moxibuston:

Involves the burning of a herb to produce smoke and heat which is applied over the body.

Rare risks include: minor bleeding or blistering.

3. Cupping & Gua-sha:

Cupping involves the application of round suction cups onto large muscular areas. Gua-sha involves the use of oil on your skin which is moved around by a smooth-edged massage instrument to apply short or long strokes to the skin.

Common side effects may include bruising.

4. Tui-na:

This treatment involves a type of Chinese massage. Common side effects may include:

Tenderness or soreness.
Allergic skin reactions to massage oils.

Please type and electronically sign to accept terms outlined above:

* If you are under the age of 18, we may require a parent or guardian to sign on your behalf

Name: *

Signature: *

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