Occupation:
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If yes, what is your employer's name?
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How did you hear about us?*
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Other - or name of person who referred you
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Name of GP/specialist:
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ACC claim number and accident date if applicable:
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If yes, how many sessions have you had?
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For your safety and protection and for our information, please answer the following questions relevant to you: Main Complaints |
1. What is the main complaint(s) you are seeking help for at Centre of Balance?
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2. Average intensity: On a scale of 1 to 10, please rate the average intensity of your main complaint (0 = no discomfort,10 = extreme discomfort):
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3. Intensity at worst: On a scale of 1 to 10, please rate the intensity of your main complaint at its worst (0 = no discomfort,10 = extreme discomfort):
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4. What was the initial cause of your main complaint(s)?
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5. When did it begin?
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6. What makes it worse? What makes it better?
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7. What have you done to try to help with this?
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8. How does this problem interfere with your daily activities? |
Work |
Standing |
Relationships |
Other |
Sleep |
Bending |
Social life |
Walking |
Stretching |
Sexually |
Sitting |
Emotionally |
Recreation |
If above is 'other', please list:
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9. Is this problem(s) aggravated by the heat or cold?
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If yes, what was the diagnosis?
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How was it confirmed?
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Others:
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11. What treatment have you received previously for this issue(s)?
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12. Do you take painkillers? If yes, how often?
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13. If we were to sit down and discuss your life 3 years from now and look back at today, what would have to have happened for you to be happy with your progress?
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14. What potential barriers do you foresee that would prevent you from achieving your Health Goals?
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15. Do you feel it is possible to eliminate or prevent these potential barriers?
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16. How important is it for you to resolve your health concerns? Rate on a scale of 1-10 (1 being lowest, 10 being highest):
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17. Do you feel that you are coachable, and would you enjoy a mentor to help you? Rate on a scale of 1-10 (1 being lowest, 10 being highest):
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18. Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals? Rate on a scale of 1-10 (1 being lowest, 10 being highest):
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19. If you have a current health condition, or have been diagnosed with one in the past, please list below (e.g. diabetes, cancer, IBS etc...):
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20. Family medical history:
Please list if any of your family members currently have a health condition, or have had one in the past (Arthritis, Cancer, Diabetes, Heart Disease, High Blood Pressure, Mental Illness, Addictions/Alcoholism, etc.):
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21. Are you taking any medications? How long have you been taking them for? Include any prescription drugs, over-the-counter medication, birth control pill etc. Please list:
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22. Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? How long have you been taking them for? Please list:
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24. If yes, where is the implant in your body?
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26. Do you have any other artificial implants? (e.g. joint replacement, metal screws etc.)
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27. Have you had any significant or recent surgeries/injuries/bone trauma/fractures or hospitalizations?
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28. Have you received any of the following vaccinations? |
Tetanus |
Diphtheria |
Pertussis |
Polio |
Measles, Mumps, Rubella |
Hepatitis A |
Hepatitis B |
Varicella (chicken pox) |
Influenza (flu) |
HPV |
Herpes Zoster (shingles) |
Other |
29. Do you have any allergies? If yes, please list:
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30. What kind of exercise do you do, if any and how often?
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31. How old is your home? years.
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32. How long have you lived there for?
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33. Do you live near any of the following |
Airport |
Dump or Landfill |
Highway |
Industrial area |
Farm or Agricultural area |
34. Have you done any recent renovations to your home? If YES, please describe (e.g. painting, new carpets etc)
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35. Do you have any household pets? If YES, what type of pet:
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36. What is your diet like? What foods do you like or dislike?
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37. Do you have any dietary restrictions? (e.g. religious, vegan/vegetarian, gluten free) If yes, please specify:
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38. Do you experience problems swallowing food? If yes, please describe:
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39. Based on your food intake for one day, what do you typically eat? |
Breakfast:
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Lunch:
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Dinner:
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40. What foods give you indigestion, if any?
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41. Do you experience any ulcers or pain in your gums? If yes, please describe:
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42. Do you smoke? If yes, how often?
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43. How many cups do you drink per day of the following beverages? |
Soda
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Alcohol
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Coffee
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Water
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45. Do you use recreational drugs? If YES, please list which kinds, and how often:
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Bodily Functions - Signs/Symptoms:
PLEASE NOTE: In Traditional Chinese Medicine, all illness stems from an imbalance in one of the five main organs, heart, liver, lungs, kidney and spleen. These questions are grouped into symptoms of illness for each organ to determine which is out of balance. Complete these questions as thoroughly as possible, please be honest with yourself. Some of the questions that follow may seem unrelated to your condition, BUT they may play a major role in diagnosis and treatment. By filling this in we will be able to give you an idea of how your conditions relate to the organs according to Chinese Medicine. All information is strictly confidential. |
46. Liver/Gall Bladder (Pineal Gland): Please tick 'none of the above' if none apply. |
Fainting |
Dizziness/poor balance/vertigo |
Numbness/tingling sensation |
Seizures/convulsions, tremors, tics |
Headache at the top & sides of the head, migraines |
Bitter taste in the mouth |
Neck & shoulder tension/tightness/pain |
Joint pain |
High-pitched ringing in ears |
Difficulty adapting to stress, teeth grinding |
Itchy eyes |
Bloodshot eyes |
Burning eyes |
Dry eyes |
Watery eyes |
Gritty eyes |
Blurry vision |
Decreased night vision |
Floaters in the eyes |
Rheumatoid Arthritis (also relates to sleep & kidneys) |
Osteoarthritis (also relates to sleep & kidneys) |
Mood swings |
Depression |
Anger |
Frequently frustrated |
Irritability |
None of the above |
47. Spleen/Stomach (Pancreas): Please select 'none of the above' if none apply. |
Low appetite |
Stomach Pain |
Nausea |
Vomiting |
Heart Burn |
Gas |
IBS |
Crohn's Disease |
Ulcerative Colitis |
Celiac Disease |
Gall Bladder removed |
Haemorrhoids |
Fatigue after eating |
Loose stools/Diarrhoea |
Undigested food in stools |
Alternating diarrhoea & constipation (also relates to liver, colon & small intestine) |
Abrupt weight gain |
Abrupt weight loss |
Heartburn/acid reflux |
Abdominal bloating |
Gurgling noises in stomach |
Bleeding, swollen/painful gums |
Frequent belching/hiccups |
Frequent/constant hunger |
Bad breath |
Canker sores in the mouth |
Weakness/atrophy in muscles |
Whole body feels heavy |
Muscle twitching/cramping/spasms |
Dry/cracked lips |
Upper tooth pain |
Muscle Pain |
Type 1 Diabetes (also relates to heart, liver, kidneys & endocrine system) |
Type 2 Diabetes (also relate to heart, liver, kidneys & endocrine system) |
Sugar cravings |
Weight gain |
Weight loss |
Sleepy after meals |
Bloated after meals |
Worry a lot |
Anxious |
None of the above |
49. Heart/Small Intestine (Pituitary Gland): Please tick 'none of the above' if none apply. |
High Blood Pressure (also relates to the spleen and liver) |
Inability to focus (ADD, ADHD) |
Angina/Chest Pain |
Chest pain traveling to shoulder |
Tight sensation in the chest (also relates to the lungs) |
Palpitations/heart fluttering |
Heart Disease |
Irregular heart beat |
Heart Attack |
Fast heart beat (above 100 beats/min) |
Heart Palpitations (feeling your heart beat) |
Slow heart beat (below 50 beats/min) |
Heart Murmurs |
Bruise easily |
High Cholesterol (also relates to the spleen and liver) |
Feel cold all the time - whole body |
Blood Clotting Disorder |
Hyperthyroid (also relates to spleen, Liver, kidney & endocrine system) |
Sores on tip of the tongue, speech problems |
Autoimmune thyroid condition (also relates to spleen, liver, kidneys & endocrine system) |
Trouble falling/staying asleep |
Bruise easily (also relates to sleep) |
Waking up unrefreshed, tired |
Sleep apnea (also relates to lungs) |
Frequent dreams |
Sleepwalking |
Mental sluggishness/fogginess |
Sleep paralysis (also relates to liver) |
Anxious (also relates to spleen & stomach) |
Not very happy in general |
Never happy at all |
Hypothyroid (also relates to spleen, liver, kidneys & endocrine system) |
Cold Hands/Feet |
None of the above |
50. Kidney/Urinary Tract/Bladder: Please select 'none of the above' if none apply. |
Kidney stones |
Memory problems (short term & long term) |
Hot flashes & night sweats |
Thirsty all the time |
Frequent cavities, teeth problems |
Sore achy, weak knees |
Lower back pain |
Excessive hair loss, premature greying of hair |
Low-pitched ringing in the ears
e |
Hearing problems |
Lack of bladder control (incontinence) |
Wake during the night at least 1 time to urinate |
Scanty Urination |
Profuse Urination |
Frequent Urination |
Urgency to urinate |
Difficult urination |
Incomplete urination |
Painful urination |
Burning urination |
Cloudy urine |
Reddish urine |
History of chronic fear/feeling fear easily/scary dreams |
Easily startled |
General weakness, low energy, chronic fatigue |
Low or no libido |
Excessively high libido |
Fluid retention (edema, heavy limbs, body, eyes) -also relates to spleen |
Swollen feet/legs/joints (also relates to spleen) |
Broken bones |
Phobias |
Hair loss |
Auto-immune disease |
Fear |
None of the above |
51. Do you experience any of the following in your bowel movements? |
Straining |
Blood in stools |
Mucus in stools |
Passing stools with pain |
Stools looks like sausages |
Stools are between sausages and loose (or watery) |
Passing stools with burning sensation |
Diarrhoea |
Loose stools |
Watery stools |
Bowel movements -once daily |
Bowel movements - twice daily |
Bowel movements - 3 times daily |
Bowel movements - 4 times or more daily |
Constipation/dry stools |
Bowel movements once every 2 days |
Bowel movements once every 3 days |
Bowel movements once every 4 days or more |
52. Do you experience any of the following in your sleep? |
Go to bed between 9pm & 10pm |
go to bed between10pm & 11pm |
go to bed between 11pm & 12am |
go to bed after 12am |
Get up between 4am & 5am |
Get up between 5am & 6am |
Get up between 6am & 7am |
Get up between 7am & 8am |
Get up between 8am & 9am |
Get up after 9am |
Suffer from insomnia |
Trouble staying asleep |
Lethargic awakening |
vivid dreams |
sleep apnoea |
sleepwalking |
sleep paralysis |
get up for night urine once |
get up for night urine 2 times |
get up for night urine 3 times |
get up for night urine 4 times |
get up for night urine 5 times and more than 5 times |
53. What is your sweating pattern like? (Time, Location, Quantity):
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54. Do you perspire a lot? If yes, day or night?
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55. Do you experience musculoskeletal pain? (e.g. joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) If yes: |
- Where is it located?
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- Is it sharp or dull pain?
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- How is it aggravated or relieved?
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- Is it acute pain or chronic?
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56. Do you have an aversion or preference to the heat or cold? Please describe:
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Men's Health- please skip if this section does not apply to you |
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58. Do you experience an erection first thing in the morning?
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Women's Health - please skip if this section does not apply to you |
59. Do you experience any of the following: |
Heavy flow |
Clotting |
Light flow |
Bleeding between periods |
Missed periods |
Breast tenderness |
PMS |
Emotional changes |
Irritability/Frustration/Anger before period |
Crying before period |
Cramps after period |
Cramps during period |
Pain during sex |
Egg-white discharge when ovulating |
Abnormal unpleasant smelling discharge monthly |
Hot flashes with sweating |
Hot flashes without sweating |
Vaginal pain |
Vaginal pain while having sex |
none of the above |
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61. Age of first menstrual period
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62. Date of last menstrual period:
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63. How long is your typical menstrual cycle (from beginning of one period to the beginning of your next period):
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64. How many days does your period last?
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68. How many times have you been pregnant?
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70. Please list your current method of contraception, if applicable
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71. What is your reaction to stress like?
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72. Have you ever experienced an anxiety or panic attack? If yes, for how long?
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73. Do you have difficulty relaxing? If yes, for how long?
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74. Are you able to concentrate? If yes, for how long?
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75. Do you have difficulty in making decisions?
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76. Do you find your memory is deteriorating? ¬¬
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Health & Wellness Levels: 77. Many factors affect our lives in various ways. These factors weave a web of health and wellbeing. Please rate your level of satisfaction in each of the areas (1 = Not happy at all, 10 = Very happy): |
Please rate your Physical Health on a scale from 1-10:
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Please rate your Mental Health on a scale from 1-10:
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Please rate your Spiritual Health on a scale from 1-10:
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Please rate your Family Health on a scale from 1-10:
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Please rate your Financial Health on a scale from 1-10:
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Please rate your Career Satisfaction on a scale from 1-10:
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Please rate your Social Health on a scale from 1-10:
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78. What type of care would you like to receive from us? |
Acute care: Obvious symptoms and signs. Get me out of pain and discomfort fast!
Most patients begin acupuncture treatment to provide relief from pain, discomfort and other symptoms fast. Acute care helps to ease your initial problem(s) quickly. |
Maintenance Care: Symptoms and signs gone completely. Feeling good, no big problems!
Maintenance care gives you a chance for deeper healing to occur. Strengthening your body's response to illness by stimulating your natural healing powers. |
Wellness & Preventative Care: Feeling great! Life is wonderful! I want to achieve optimal health and well-being, to be free of disease and illness.
Wellness Care is your best choice. |
79. Is there anything else you would like to add that you feel is important and has not been covered?
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Name of GP:
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Clinic of GP:
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Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:
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In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of access to and correction of your personal information held by this practice. No information will be given to a third party without your permission. Consent to Treatment I HEREBY give my consent for acupuncture/acupressure treatment bearing in mind that a full verbal explanation has been given at the time of treatment. I AGREE to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I UNDERSTAND that I must pay for private treatments, cancellation fees and the costs of materials (splints, strappings etc.) and herbs, and any treatments declined by ACC/work insurance. I UNDERSTAND that herbs are not refundable. I UNDERSTAND that any unpaid bills may be referred to a debt collector and I agree that I will be responsible for the debt collection fees, and the administration fee of $50 incurred for accounts sent to debt collection. I UNDERSTAND that I have the right to decline part or all of the treatment offered to me at any time and I can ask for a second opinion or change my treatment provider in accordance with Section 7 of the Code of Health & Disability Services Consumer Rights 1996. I UNDERSTAND that I can ask the staff for an explanation of treatment I am receiving at any time and that in accordance with Section 10 of the Code of Health and Disability Services Consumer Rights 1996, I have the right of complaint. I UNDERSTAND that there is a 24-hour cancellation and rescheduling policy that will result in a fee of the full price of treatment should I not give sufficient notice. It is our policy to collect private payment for ACC treatments until the ACC claim is showing on the ACC website as being approved. We will refund the difference once the claim is approved. |