Pacific Wellness Institute Clinic: Bloor-Yorkville Toronto

Patient Form

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.

 

Personal Data

Title

Family Name*

Given Name*

Height

Weight

Address*

City*

Province*

Postal Code*

Phone* (Best number to reach you)

Phone (Alternate number)

Email*

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 online, please indicate the source(s) and details:

GoogleGoogle mapBingYelpFacebookvia other websiteother

Are you claiming all or part of our fee under insurance?

AllPartNo

Does your insurance company allow direct billing from us?

YesNoDon'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?

YesNo

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:
*

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

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?

YesNo

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

YesNo

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

YesNo

Do you notice an increase or decrease in your symptom(s) depending on the time of month (according to menstruation cycle)?

YesNo

List surgeries, accidents, falls:

If you have the following conditions(past or present), please check below, and include details (if any)

Heart ProblemsSpinal/Joint DisorderHigh Blood PressureAnemiaDiabetesEpilepsyConstipationTumor/CancerRespiratory ProblemsDizzinessLow Blood PressureInternal Pins/WiresOsteoporosisAllergiesDiarrheaBlood ClotsCirculation Problems
FaintingSkin ProblemsDecreased SensationHigh CholesterolLow Blood SugarHormonal DisorderChest PainPalpitationsAsthmaSleep ApneaDifficulty BreathingCollapsed Lung(s)Varicose VeinsSeizuresVision/Hearing LossHeadachesOther

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:

HepatitisSkin Diseases/InfectionsSTD
HIV (AIDS)Herpes

Have you ever experienced any of the following?

Dizziness or lightheadedness when standing quickly from sitting positionTingling, numbness, or prickling sensation in hands and feetFainting, dizziness or nausea during routine Doctor's visits or blood donationAcute illness or condition that required emergency visitsCondition that required hospitalization

Details

Please indicate if you have experienced any of the following
in the last 12 months.

Reoccurring persistent infection1 in bladder,skin,gums,genitals

Diarrhea (loose watery stool)Alternating constipation and diarrheaChanges 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 EasilyDecreased Energy

For women only

Are you pregnant?

YesNoMaybe

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 flowPre-menstrual symptoms (PMS)Clear vaginal dischargeHeavy blood flowCheesy white dischargeWhite vaginal dischargeIrregular menstrual cycleGreenish or yellow dischargeMenstrual Pain, crampsAbsence of periodsLower Back Pain
Abdominal BloatingBrittle Hair/NailsBrown DischargeClotted Blood in MensesDischarge from NipplesPainful IntercourseExcess Body or Facial HairAcne/Skin ProblemsPainful UrinationVaginal DrynessOther

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:

How is your:

Sleep

PoorFairGoodVery Good

Stress

PoorFairGoodVery Good

Appetite

PoorFairGoodVery Good

Energy

PoorFairGoodVery Good

Do you smoke? YesNo
If so, how many/day?

Do you drink? YesNo
If so, what, how often, and how much?

Do you regularly consume any caffeine containing drinks (e.g., tea, coffee)?
YesNo
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?
YesNo

Do you feel bloated after almost every meal?
YesNo

If you have bloating, what usually makes it worse?

Which part of your abdomen becomes distended immediately after a heavy meal:
TopMiddleLower

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

Before Breakfast

Breakfast

Between

Lunch

Between

Dinner

After Dinner

Bowel Movements

Comments

Day 2

Before Breakfast

Breakfast

Between

Lunch

Between

Dinner

After Dinner

Bowel Movements

Comments

Day 3

Before Breakfast

Breakfast

Between

Lunch

Between

Dinner

After Dinner

Bowel Movements

Comments