Acupuncture Clinic Toronto
Click to learn about the conditions we treat at our clinic

No Payment,
No Paperwork,
No Hassle

Direct insurance billing available for
MASSAGE THERAPY

SHIATSU

REFLEXOLOGY

ACUPUNCTURE




If you have employee benefits, we may be able to bill your insurance company directly for your treatments.
Click here for details



New Patient Information



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416-929-6958


Online Patient Forms
General Questionnaire
Diet/Lifestyle Questionnaire


Insurance and Payment Information


Out of Town Patient Information


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Please complete this form as thoroughly as possible. The information provided is kept confidential according to The Pacific Wellness Institute Privacy Policy.  This completed form is required before your session.

Date: 
Personal data
Title:
Family Name:
Given Name:
Height:
Weight:
Address:
City:
Province:
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E-mail:
Date of Birth - -
Occupation:
How did you hear about us? (please specify):
If you are referred, please indicate the name of the person who referred you:

Did the person who referred you suggest that you see any particular practitioner at Pacific Wellness? If so, whom? 

If you found us through a website, please indicate the site you found first:

www.pacificwellness.ca
www.acupuncture-treatment.com
www.
Are you claiming all or part of our fee under insurance?

Yes

    All

No

    Part
Does your insurance company allow direct billing from us?

 Yes

 No

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If you are involved in an unsettled car accident case please indicate here
Family Physician:
When was your last check up?
Results
Have you ever had any acupuncture treatment before?
If so,
Name of previous acupuncturist
When was your last visit?
Briefly describe your experience
Please answer these questions:
Please list your health concerns that you want us to address in order of importance:

Health concerns

For how long





If any other health practitioners are involved in the care of the condition(s) you indicated, please list their names and specialties

Select areas and level of pain, discomfort or any other symptoms
Area Discomfort
Head
Neck
Shoulders
Chest
Upper Arms
Elbows
Lower Arms
Wrists
Fingers
Upper Abdomen
Mid Abdomen
Lower Abdomen
Upper Back
Mid Back
Lower Back
Buttocks
Genitalia
Upper Legs
Lower Legs
Ankles
Toes

If you are experiencing pain symptoms, please indicate the intensity of pain:
(0 being no pain and 10 being the worst pain ever)

Do you notice an increase or decrease in your symptom(s) depending on the time of day? 

  Yes
  No

Do you notice an increase or decrease in your symptom(s) depending on the weather?   Yes
  No
Do you notice an increase or decrease in your symptom(s) depending on the time of year?   Yes
  No
Do you notice an increase or decrease in your symptom(s) depending on the time of month (according to menstruation cycle)?   Yes
  No
List surgery, accidents, falls:
Date Details
If you have the following conditions(past or present), please check below, and include details (if any):
Heart Problems Spinal/Joint Disorder
High Blood Pressure Anemia
Diabetes Epilepsy
Constipation Tumor/Cancer
Respiratory Problems Dizziness
Low Blood Pressure Internal Pins/Wires
Osteoporosis Allergies
Diarrhea Blood Clots
Circulation Problems Fainting
Skin Problems Decreased Sensation
High Cholesterol Low Blood Sugar
Hormonal Disorder Chest Pain
Palpitations Asthma
Sleep Apnea Difficulty Breathing
Collapsed Lung(s) Varicose Veins
Seizures Vision/Hearing Loss
Headaches Other
Details:
 
Are you experiencing anxiety or depression or suffering from any mental/emotional disorders?
Please indicate if you had (or currently have) any of the following:
Hepatitis HIV (AIDS)
Skin Diseases/Infections Herpes
STD  
Other Infectious Disease
Have you ever experienced any of the following?
Dizziness or lightheadedness when standing quickly from sitting position
Tingling, numbness, or prickling sensation in hands and feet
Fainting, dizziness or nausea during routine Doctor's visits or blood donation
Acute illness or condition that required emergency visits
Condition that required hospitalization
Details:
Please indicate if you have experienced any of the following
in the last 12 months.
Reoccurring persistent infection in bladder, skin, gums, or genitals
Unexplained weight loss of 10 pounds or more
Diarrhea (loose watery stool)
Alternating constipation and diarrhea
Changes in bowel function (constipation, diarrhea, black stool, difficulty controlling etc.)
Changes in urinary function (change of frequency, incontinence, dark urine, blood in urine, etc.)
Bruise Easily
Decreased Energy

For women only

Are you pregnant?
If so, How many months?
Typical Length of Cycle (days)
First Day of your Last Period
Age at which menses began
How Many Days do you Normally Bleed?
Past Pregnancies (when, how many)
Check all that apply
Scanty blood flow Pre-menstrual symptoms (PMS)
Clear vaginal discharge Heavy blood flow
Cheesy white discharge White vaginal discharge
Irregular menstrual cycle Greenish or yellow discharge
Menstural Pain, cramps Absence of periods
Lower Back Pain Abdominal Bloating
Brittle Hair/Nails Brown Discharge
Clotted Blood in Menses Discharge from Nipples
Painful Intercourse Excess Body or Facial Hair
Acne/Skin Problems Painful Urination
Vaginal Dryness Other
Please indicate if you have any other health conditions that were not already mentioned.
Miscellaneous
If you are taking any medication, vitamins, herbs, or nutritional supplements please list below:
Drug Name Dosage Condition Duration
Supplement Dosage Condition Duration
How is your:
Sleep
Poor      Fair      Good      Very Good
Stress
Low      Fair      High      Very High
Appetite
Poor      Fair      Good      Very Good
Energy
Low      Fair      High      Very High
Do you smoke?  Yes  No If  so, how many/day?
Do you drink?  Yes No If so, what, how often, and how much?
Do you regularly consume any caffeine containing drinks (e.g., tea, coffee)?
Yes No
If so, what and how much?
If you are aware of any notable chemical or heavy metal exposures please indicate:
Do you skip meals often?   Yes   No
Do you feel bloated after almost every meal?    Yes   No
If you have bloating, what usually makes it worse?
Which part of your abdomen becomes distended immediately after a heavy meal:
How many glasses of water do you drink a day:  
Tap: Bottled:
Filtered:
  Type: Type:

If you have any life threatening allergies (e.g., anaphylaxis, medication), please list here:

In case of emergency  call:

Name
Relationship
Phone
Family History

Please describe the health status of your family (e.g., heart disease, high blood pressure, diabetes, cancer, rheumatoid arthritis, psychiatric illness, etc.).
Father

Mother

Other families


Please utilize space below if you need to make any additional statements:

Your diet for the last 3 days

  Day 1
  Food Beverages
Before Breakfast
Breakfast
Between
Lunch
Between
Dinner
After Dinner
Bowel Movements
Comments
  Day 2
  Food Beverages
Before Breakfast
Breakfast
Between
Lunch
Between
Dinner
After Dinner
Bowel Movements
Comments
  Day3
  Food Beverages
Before Breakfast
Breakfast
Between
Lunch
Between
Dinner
After Dinner
Bowel Movements
Comments

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The Pacific Wellness Institute
80 Bloor St. West, Suite 1100, Toronto, ON M5S-2V1, Canada
416-929-6958

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Acupuncture and alternative medicine in Toronto from Pacific Wellness.
Acupuncture, shiatsu, RMT massage, naturopathy, reflexology and other alternative modalities for wellness, weight loss, fertility, pain control.