Pacific Wellness

Click to learn about the conditions we treat at our clinic

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Direct insurance billing available for
MASSAGE
SHIATSU
NATUROPATHY
ACUPUNCTURE
REFLEXOLGY

Massage

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

Online Patient Forms

General Questionnaire

Diet/Lifestyle Questionnaire

Insurance and Payment Information

Out of Town Patient Information

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Employment

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:

Postal Code:

Home phone :

( ) -

Work phone:

( ) -

Fax:

( ) -

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

Don't Know

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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