Acupuncture Initial Form

About Your Session

Traditional Chinese Medicine is a holistic health therapy that involves balancing the Yin and Yang of the body through massage techniques such as guasha (spooning), Acupuncture, herbal formulae, dietary and lifestyle advice as well as breathing techniques.

Full name:

Have you seen a Chinese Medicine Doctor before?
YesNo

Have you ever had any trouble with Chinese herbal medicine / acupuncture?
YesNo

Are you pregnant?
YesNo

Have you ever had surgery? If yes, please explain.
YesNo

Are you allergic or sensitive to any oil (essential oils, nut oils, scents)? If yes, please list.
YesNo

Have you ever had any of the following?
AsthmaDiabetesEpilepsyExcessive BleedingHeart AilmentHepatitisHIVOther Infectious DiseasesHigh Blood PressureLow Blood PressureKidney DiseaseNeck InjuriesSpinal InjuriesRheumatic FeverStaphylococcusSkin Disease

Disclaimer I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures, including various modes of physiotherapy on me by the acupuncturist at Simply Natural Therapies and/or other licensed acupuncturists who now or in the future treat me while working or associated with Simply Natural Therapies. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping & gua sha, electrical stimulation, breathing techniques, exercise therapy Tui-Na (Chinese massage), Chinese or western herbal medicine, and nutritional counselling. I am aware that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. I understand that I should not make significant movements while the needles are being inserted, retained, or removed. Bruising is a common side effect of cupping and gua sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturists at Simply Natural Therapies use sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment other side effects and risks may occur. I will notify the acupuncturist who is caring for me if I am or become pregnant. I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the acupuncturist to exercise judgment during the course of treatment which the acupuncturist thinks at the time, based upon the facts then known, is in my best interest. By typing my name below and clicking submit I confirm that I have read, or have had read to me, this consent to treatment, and am aware of the risks and benefits of acupuncture and other procedures. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Full name: