First Name *

Last Name *

Occupation

Gender

DOB *

Height

Weight

Address *

City *

Zip / Postal code *

Email *

Would you like email appointment reminders?

Yes

No

Home Phone # *

Secondary Phone # *

Family Dr *

City *

Doctor Phone # *

Doctor Fax # *

Referral Source *

Emergency Contact Name: *

Emergency Phone # *

Relationship to patient

(If Applicable) WSIB (Workplace Injury) patients

Are you a WSIB patient? *

Yes

No

(If Applicable) MVA (Motor Vehicle Accident) Patients

Are you an MVA patient? *

Yes

No

Lawyer Information

Name of Law Firm

Name of Lawyer

Lawyer Address

Lawyer Phone #

Lawyer Fax #

Lawyer Email

Acupuncture

Past Medical History Please list any relevant past medical history including any hospitalizations, surgeries, prior injuries, or any past medical conditions etc. be sure to include any previous family medical conditions or diseases that may be relevant

Ongoing Health conditions/Allergies/ Drug Reactions/ Risk Factors/ Long term treatment Please list any ongoing health conditions, allergies, drug reactions, and long term treatments that may be relevant. If you are currently taking any prescription medications please include them.

Please check mark any conditions you are experiencing (past and present)

General symptoms

Headaches/migraines

Fever

Chills

Sweat

Memory loss

Dizziness/Lightheadedness

Fainting

Stress/Depression

Discoordination

Nervousness

Recent weight loss/gain

Numbness pain in arms/legs

Cardiovascular

High or low blood pressure

Previous stroke or TIA

High cholesterol

swelling of ankles

poor circulation

stroke/heart attack

irregular heart beat

shortness of breath

pain over heart

Oral

Gum trouble

Dental decay

Frequent colds

Enlarged thyroid

Tonsillitis

Sinus infection

Nasal drainage

Enlarged glands

Respiratory

Wheezing

Chronic cough

Spitting up phlegm

Chest pain

Difficulty breathing

Genitourinary system

Genitourinary system

Blood in urine/stool

Mucus in stool

Kidney infection/kidney stone

Bladder infection

Inability to control urine

Skin

Skin conditions/rashes

Itching

Bruising easily

Dryness

Boils

Varicose veins

Sensitive skin

Hives or allergies

Women Only

Cramps/backache

Previous miscarrage

Irregular cycle

Vaginal discharge

Lumps in breast

Menopausal symptoms

Pregnant

Painful menstruations

Excessive flow

Excessive flow

Hysterectomy

Muscle and joints

Stiff neck

Back ache

Swollen joints

Painful tailbone

Pain in shoulders

Hernia

Spinal curvature

Faulty posture

Arthritis

Foot trouble

Ears, eyes, nose and throat

Hearing loss

Vision problems

Glaucoma

Ringing in ear(s)

Crossed eyes

Eye pain

Deafness

Earache

Ear discharge

Nose bleeds

Nasal obstruction

Sore throat

Hoarseness

Hay fever

Asthma

Gastrointestinal

Poor appetite

Distress From greasy foods

Excessive hunger/thirst

Nausea

Vomiting

Burning in stomach

Constipation/diarrhea

Colon trouble

Liver trouble/hepatitis

Gallbladder

Ulcers

Colitis

Hemorrhoids

Hypoglycemia

Hiatal hernia

Metallic taste

Have you any of the following?

Appendicitis

Osteoporosis

Whooping cough

Anaemia

Measles

Mumps

Pleurisy

Parkinson’s

Malaria

Diabetes

Cancer

Heart disease

Goitre

Influenza

Pneumatic fever

HIV/AIDS

Chicken pox

Venereal infection

Epilepsy

Tuberculosis

Eczema

Gout

Arthritis

Alcoholism

Cold sores

Multiple sclerosis

Pneumonia

Mental illness

Polio

Rubella

Signature of patient (or substitute decision maker)

Signature

Clear

Date