Consultation Form

Save your time at the clinic

Please complete the form and click the ‘Submit’ button at the bottom of the page. This information allows us to assess your health condition prior to your arrival.
Your personal and health information is collected, stored, and used securely and solely for the purpose of your health assessment.

We are committed to protecting your privacy. You have the right to give, withhold, or withdraw your consent at any time regarding the collection, use, or disclosure of your Personal Health Information (PHI), in accordance with applicable privacy laws.
If you have any questions about how your information is handled or would like to update your consent preferences, please contact us directly.

Questionnaires that we need to know about you and your general health.

Please answer all of the following questions so that we can treat your current condition most effectively. The more accurate the better results.

Your Name *

First

Last

Date of Birth *

Gender *

Marital Status *

Home Phone

Cell Phone

Work Phone

Emergency Contact Number *

Name of the Emergency Contact *

Your Addresss *

City *

Province *

Postal Code *

Email *

Your Occupation

Do you have Extended Health Insurance Coverage?

If you have health insurance coverage, which service(s) are covered?

Acupuncture
RMT Massage
Not Sure

Please check all services that are covered. If you are not sure about service item, check 'Not Sure'.

If you are referred by someone, could you give us the name?

Is this your first time consultation with us?

What is your Chief Complaint? *

Please describe what made you seek for treatment. For example, lower back pain.

For how long or since when you've been experiencing this problem?

Do you know what caused this problem?

Could you describe your current symptoms and signs?

Please describe details of your current problem if possible. For example, sharp pain at lower back with difficulty in moving the back that becomes worse at night, affecting sleep quality.

What makes your condition better?

What makes your condition worse?

Have you had lab tests or disease diagnosis for your condition?

Please list all medications you are currently taking.

Your ongoing health concerns

Please indicate your current health condition with or without treatment, prescription or an risk factors such as infectious agent that you are aware of.

If you have food aversions, please list the names of food

Thirst

No thirst
Thirst with desire to drink cold fluids
Thirst with desire to drink warm fluids
Thirsty but no desire to drink

Approximately how many times do you urinate a day?

Urination: Amount

Normal
Scanty
Copious

Approximately how many times do you defecate a day or a week?

Approximately how many hours do you sleep a night?

How would you describe your level or stress? Out of 10, 10 being the highest level of stress.

How would you describe your level or energy? Out of 10, 10 being the highest level of energy.

Female Only: I had my first menstruation at age:

Female Only: Menstrual cycle

Such as 28 days, every 4 months, irregular, delayed, or early, etc.

Female Only: Color of menstrual blood

Normal red
Light red
Dark red

Female Only: Clots

No clots
Big clots
Small clots

Female Only: Cramps

No cramps
Mild cramps
Severe cramps
Need take pills

Female Only: Are you on contraceptive pills?

Female Only: Are you pregnant?

Female Only: Are you menopaused?

Female Only: Do you have belly button piercing?

Female Only: Do you have vaginal discharge?

Female Only: If you have vaginal discharge, could you describe the color, amount, and odor?

Female Only: How many times were you pregnant?

Female Only: How many times did you give birth (number of childbirth)?

Female Only: Number of miscarriage

Female Only: Number of abortion

Other Comments