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New Patient Form


Please note: This is a long form. You may need half an hour to complete it. 

Date: July 21, 2024

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Information
Preferred consultation location:*
Dinsdale Clinic
Zoom

Occupation:
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

Please give the name of the person who referred you if you ticked Word of Mouth/Other in the above

Name of referring GP/specialist if applicable:

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?

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?

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):

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):

4. What was the initial cause of your main complaint(s)?

5. When did it begin?

6. What makes it worse? What makes it better?

7. What have you done to try to help with this?
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:

9. Is this problem(s) aggravated by the heat or cold?
10. Has this problem(s) been medically diagnosed?*
No
Yes

If yes, what was the diagnosis?

How was it confirmed?
Blood Test (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes
X-rays (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes

Others:

11. What treatment have you received previously for this issue(s)?
12. Do you take painkillers? If yes, how often?

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?

14. What potential barriers do you foresee that would prevent you from achieving your Health Goals?

15. Do you feel it is possible to eliminate or prevent these potential barriers?

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):

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):

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):

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...):

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.):

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:

22. Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? How long have you been taking them for? Please list:
23. Do you have any metal implants in your body?*
No
Yes

24. If yes, where is the implant in your body?
25. Do you wear a hearing aid or pacemaker?*
No
Yes

26. Do you have any other artificial implants? (e.g. joint replacement, metal screws etc.)

27. Have you had any significant or recent surgeries/injuries/bone trauma/fractures or hospitalizations?
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)
Covid 19
Other

29. Do you have any allergies? If yes, please list:

30. What kind of exercise do you do, if any and how often?

31. How old is your home? years.

32. How long have you lived there for?
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)

35. Do you have any household pets? If YES, what type of pet:

Diet:


36. What is your diet like? What foods do you like or dislike?

37. Do you have any dietary restrictions? (e.g. religious, vegan/vegetarian, gluten free) If yes, please specify:

38. Do you experience problems swallowing food? If yes, please describe:

39. Based on your food intake for one day, what do you typically eat?


Breakfast:

Lunch:

Dinner:

40. What foods give you indigestion, if any?

41. Do you experience any ulcers or pain in your gums? If yes, please describe:
42. Do you smoke? If yes, how often?

43. How many cups do you drink per day of the following beverages?


Soft drinks

Alcohol

Coffee

Water
44. Are you regularly exposed to second-hand smoke*
No
Yes
I don't know

45. Do you use recreational drugs? If YES, please list which kinds, and how often:

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.
Seizures/convulsions, tremors, tics
Fainting
Dizziness/poor balance/vertigo
Numbness/tingling sensation
Headache at the top & sides of the head, migraines
Neck & shoulder tension/tightness/pain
Bitter taste in the mouth
Teeth grinding
High-pitched ringing in ears
Itchy eyes
Dry eyes
Burning eyes
Bloodshot eyes
Watery eyes
Gritty eyes
Blurry vision
Decreased night vision
Floaters in the eyes
Joint pain
Rheumatoid Arthritis (also relates to spleen & kidneys)
Osteoarthritis (also relates to spleen & kidneys)
Difficulty adapting to stress
Mood swings
Depression
Anger
Frequently frustrated
Irritability
None of the above
47. Spleen/Stomach (Pancreas): Please select 'none of the above' if none apply.
Type 1 Diabetes (also relates to heart, liver, kidneys & endocrine system)
Type 2 Diabetes (also relate to heart, liver, kidneys & endocrine system)
IBS
Crohn's Disease
Ulcerative Colitis
Low appetite
Abdominal bloating
Stomach Pain
Nausea
Vomiting
Heart Burn/acid reflux
Gas
Celiac Disease
Gall Bladder removed
Haemorrhoids
Loose stools/Diarrhoea
Undigested food in stools
Alternating diarrhoea & constipation (also relates to liver, colon & small intestine)
Abrupt weight gain
Weight gain
Abrupt weight loss
Weight loss
Gurgling noises in stomach
Bleeding, swollen/painful gums
Frequent belching/hiccups
Frequent/constant hunger
Bad breath
Canker sores in the mouth
Whole body feels heavy
Dry/cracked lips
Upper row tooth pain
Weakness/atrophy in muscles
Muscle twitching/cramping/spasms
Muscle Pain
Sugar cravings
Fatigue after eating
Sleepy after meals
Bloated after meals
Worry a lot
Anxious (also relates to Heart)
None of the above
48. Lungs/Colon
Shortness of breath
Stuffiness
Sinus infections
Sinus pain
Nosebleeds
Hay fever
Runny nose
Frequent colds/flu
Acne
Skin disorders
Psoriasis
Eczema
Hives
Skin itching
Skin rashes
Skin redness
Changes in moles
Cough
Chest congestion
Wheezing
Asthma
COPD (chronic obstructive pulmonary disease)
Sputum (phlegm)
Sore throat
Trouble swallowing
Bottom row tooth pain
Sadness
Crying/weeping
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)
High Cholesterol (also relates to the spleen and liver)
Hyperthyroid (also relates to spleen, liver, kidney & endocrine system)
Autoimmune thyroid condition (also relates to spleen, liver, kidneys & endocrine system)
Heart Disease
Heart Murmurs
Inability to focus (ADD, ADHD)
Heart Attack
Tight sensation in the chest (also relates to the lungs)
Angina/Chest Pain
Chest pain traveling to shoulder
Heart palpitations (feeling your heart beat)
Heart fluttering
Irregular heart beat
Fast heart beat (above 100 beats/min)
Slow heart beat (below 50 beats/min)
Bruise easily (also relates to spleen)
Feel cold all the time - whole body
Cold Hands/Feet
Sores on tip of the tongue, speech problems
Trouble falling asleep
Trouble staying asleep
Frequent dreams
Sleep apnea (also relates to lungs)
Sleepwalking
Sleep paralysis (also relates to liver)
Blood Clotting Disorder
Waking up unrefreshed, tired
Speech problems
Mental sluggishness/fogginess
Heavy head
Anxious (also relates to spleen & stomach)
Not very happy in general
Never happy at all
Hypothyroid (also relates to spleen, liver, kidneys & endocrine system)
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
Hearing problems
Lack of bladder control (incontinence)
Wake during the night at least once 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 libido
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
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)
Loose stools
Watery stools
Diarrhoea
Passing stools with burning sensation
Bowel movements -once daily
Bowel movements - twice daily
Bowel movements - 3 times daily
Bowel movements - 4 times or more daily
Bowel movements once every 2 days
Bowel movements once every 3 days
Bowel movements once every 4 days or more
Constipation/dry stools
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 twice
get up for night urine 3 times
get up for night urine 4 times
get up for night urine 5 or more times

53. Do you perspire a lot?

53.1 What is your sweating pattern like? (Time, Location, Quantity):

54. 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?

- Is it sharp or dull pain?

- How is it aggravated or relieved?

- Is it acute pain or chronic?

55. Do you have an aversion or preference to the heat or cold? Please describe:
56. Have you ever had a sexually transmitted disease/infection?
Chlamydia
Gonorrhoea
Syphilis
Herpes
Other
None

Men's Health- please skip if this section does not apply to you

57. Are you sexually active?*
No
Yes
58. Do you experience an erection first thing in the morning?

Women's Health - please skip if this section does not apply to you

59. Do you experience any of the following:
Heavy flow
Light flow
Bleeding between periods
Missed periods
Clotting
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
60. Do you still have a menstrual period?*
No
Yes

61. Age of first menstrual period

62. Date of last menstrual period:

63. How long is your typical menstrual cycle (from beginning of one period to the beginning of your next period):

64. How many days does your period last?
65. Are you currently pregnant?*
No
Yes
I don't know
66. Are you trying to become pregnant?*
No
Yes
67. Are you currently breastfeeding?*
No
Yes

68. How many times have you been pregnant?
69. Are you currently sexually active?*
No
Yes

70. Please list your current method of contraception, if applicable

Emotions:


71. What is your reaction to stress like?

72. Have you ever experienced an anxiety or panic attack? If yes, for how long?

73. Do you have difficulty relaxing? If yes, for how long?

74. Are you able to concentrate? If yes, for how long?

75. Do you have difficulty in making decisions?

76. Do you find your memory is deteriorating?

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:

Please rate your Mental Health on a scale from 1-10:

Please rate your Spiritual Health on a scale from 1-10:

Please rate your Career Satisfaction on a scale from 1-10:

Please rate your Family Health on a scale from 1-10:

Please rate your Social Health on a scale from 1-10:

Please rate your Financial Health on a scale from 1-10:
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?
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future? *
No
Yes

Name of GP:

Clinic of GP:
May we contact your doctor to provide them with updates about your progress?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

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.

Telehealth Consultation - Patient Consent, Disclaimer and Release (The following applies to patients who are having telehealth consultations).

I hereby attest that I have requested and authorized Szenan Phua (The Practitioner) to arrange an online consultation for me with him. Via this consultation The Practitioner will assess my condition and offer advice on use of self acupressure to treat my condition at home and/or prescribe herbs. I will be responsible for finding a place to fill the herbal prescription. The Practitioner will base this assessment solely on the information provided by me to him via a patient form and the consultation itself.

I understand and agree that:

· The Practitioner’s telehealth consultation is solely based on the information provided by me and, in the absence of a physical evaluation, The Practitioner may not be aware of certain facts that may limit or affect his assessment or diagnosis of my condition and recommended treatment.

· The telehealth consultation is very different from a regular face-to-face examination and that The Practitioner is limited by the information provided by me. Accordingly, the diagnosis I will receive is limited and provisional.

· A telehealth consultation is not intended to replace a full face-to-face evaluation.

· I will not have direct contact with The Practitioner unless I decide to travel to Hamilton, New Zealand for an evaluation afterwards.

· The Practitioner is only rendering a telehealth consultation and does not assume any responsibility for my continued medical care or treatment.

· I am responsible for all the expenses related to my telehealth consultation request including, but not limited to, consultation fees, phone charges if necessary.

· My medical information will be handled with strict confidentiality, privacy and security; however, I understand there are risks associated with any electronic transfer process from one location to another.

· I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.



Disclaimer and Release

I hereby completely and irrevocably release Ji De Tang Ltd and Szenan Phua and Phua Ltd and their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the “Ji De Tang Ltd Released Parties”) of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the telehealth consultation, conclusions or recommendations provided by Ji De Tang Ltd or The Practitioner. Furthermore, I agree that the Ji De Tang Ltd Released Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.

By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.

As a condition to receiving the telehealth consultation service, I have read and acknowledge that I have given this consent of my own free will.

First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's Information
Preferred consultation location:*
Dinsdale Clinic
Zoom

Occupation:
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

Please give the name of the person who referred you if you ticked Word of Mouth/Other in the above

Name of referring GP/specialist if applicable:

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?

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?

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):

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):

4. What was the initial cause of your main complaint(s)?

5. When did it begin?

6. What makes it worse? What makes it better?

7. What have you done to try to help with this?
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:

9. Is this problem(s) aggravated by the heat or cold?
10. Has this problem(s) been medically diagnosed?*
No
Yes

If yes, what was the diagnosis?

How was it confirmed?
Blood Test (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes
X-rays (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes

Others:

11. What treatment have you received previously for this issue(s)?
12. Do you take painkillers? If yes, how often?

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?

14. What potential barriers do you foresee that would prevent you from achieving your Health Goals?

15. Do you feel it is possible to eliminate or prevent these potential barriers?

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):

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):

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):

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...):

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.):

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:

22. Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? How long have you been taking them for? Please list:
23. Do you have any metal implants in your body?*
No
Yes

24. If yes, where is the implant in your body?
25. Do you wear a hearing aid or pacemaker?*
No
Yes

26. Do you have any other artificial implants? (e.g. joint replacement, metal screws etc.)

27. Have you had any significant or recent surgeries/injuries/bone trauma/fractures or hospitalizations?
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)
Covid 19
Other

29. Do you have any allergies? If yes, please list:

30. What kind of exercise do you do, if any and how often?

31. How old is your home? years.

32. How long have you lived there for?
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)

35. Do you have any household pets? If YES, what type of pet:

Diet:


36. What is your diet like? What foods do you like or dislike?

37. Do you have any dietary restrictions? (e.g. religious, vegan/vegetarian, gluten free) If yes, please specify:

38. Do you experience problems swallowing food? If yes, please describe:

39. Based on your food intake for one day, what do you typically eat?


Breakfast:

Lunch:

Dinner:

40. What foods give you indigestion, if any?

41. Do you experience any ulcers or pain in your gums? If yes, please describe:
42. Do you smoke? If yes, how often?

43. How many cups do you drink per day of the following beverages?


Soft drinks

Alcohol

Coffee

Water
44. Are you regularly exposed to second-hand smoke*
No
Yes
I don't know

45. Do you use recreational drugs? If YES, please list which kinds, and how often:

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.
Seizures/convulsions, tremors, tics
Fainting
Dizziness/poor balance/vertigo
Numbness/tingling sensation
Headache at the top & sides of the head, migraines
Neck & shoulder tension/tightness/pain
Bitter taste in the mouth
Teeth grinding
High-pitched ringing in ears
Itchy eyes
Dry eyes
Burning eyes
Bloodshot eyes
Watery eyes
Gritty eyes
Blurry vision
Decreased night vision
Floaters in the eyes
Joint pain
Rheumatoid Arthritis (also relates to spleen & kidneys)
Osteoarthritis (also relates to spleen & kidneys)
Difficulty adapting to stress
Mood swings
Depression
Anger
Frequently frustrated
Irritability
None of the above
47. Spleen/Stomach (Pancreas): Please select 'none of the above' if none apply.
Type 1 Diabetes (also relates to heart, liver, kidneys & endocrine system)
Type 2 Diabetes (also relate to heart, liver, kidneys & endocrine system)
IBS
Crohn's Disease
Ulcerative Colitis
Low appetite
Abdominal bloating
Stomach Pain
Nausea
Vomiting
Heart Burn/acid reflux
Gas
Celiac Disease
Gall Bladder removed
Haemorrhoids
Loose stools/Diarrhoea
Undigested food in stools
Alternating diarrhoea & constipation (also relates to liver, colon & small intestine)
Abrupt weight gain
Weight gain
Abrupt weight loss
Weight loss
Gurgling noises in stomach
Bleeding, swollen/painful gums
Frequent belching/hiccups
Frequent/constant hunger
Bad breath
Canker sores in the mouth
Whole body feels heavy
Dry/cracked lips
Upper row tooth pain
Weakness/atrophy in muscles
Muscle twitching/cramping/spasms
Muscle Pain
Sugar cravings
Fatigue after eating
Sleepy after meals
Bloated after meals
Worry a lot
Anxious (also relates to Heart)
None of the above
48. Lungs/Colon
Shortness of breath
Stuffiness
Sinus infections
Sinus pain
Nosebleeds
Hay fever
Runny nose
Frequent colds/flu
Acne
Skin disorders
Psoriasis
Eczema
Hives
Skin itching
Skin rashes
Skin redness
Changes in moles
Cough
Chest congestion
Wheezing
Asthma
COPD (chronic obstructive pulmonary disease)
Sputum (phlegm)
Sore throat
Trouble swallowing
Bottom row tooth pain
Sadness
Crying/weeping
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)
High Cholesterol (also relates to the spleen and liver)
Hyperthyroid (also relates to spleen, liver, kidney & endocrine system)
Autoimmune thyroid condition (also relates to spleen, liver, kidneys & endocrine system)
Heart Disease
Heart Murmurs
Inability to focus (ADD, ADHD)
Heart Attack
Tight sensation in the chest (also relates to the lungs)
Angina/Chest Pain
Chest pain traveling to shoulder
Heart palpitations (feeling your heart beat)
Heart fluttering
Irregular heart beat
Fast heart beat (above 100 beats/min)
Slow heart beat (below 50 beats/min)
Bruise easily (also relates to spleen)
Feel cold all the time - whole body
Cold Hands/Feet
Sores on tip of the tongue, speech problems
Trouble falling asleep
Trouble staying asleep
Frequent dreams
Sleep apnea (also relates to lungs)
Sleepwalking
Sleep paralysis (also relates to liver)
Blood Clotting Disorder
Waking up unrefreshed, tired
Speech problems
Mental sluggishness/fogginess
Heavy head
Anxious (also relates to spleen & stomach)
Not very happy in general
Never happy at all
Hypothyroid (also relates to spleen, liver, kidneys & endocrine system)
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
Hearing problems
Lack of bladder control (incontinence)
Wake during the night at least once 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 libido
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
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)
Loose stools
Watery stools
Diarrhoea
Passing stools with burning sensation
Bowel movements -once daily
Bowel movements - twice daily
Bowel movements - 3 times daily
Bowel movements - 4 times or more daily
Bowel movements once every 2 days
Bowel movements once every 3 days
Bowel movements once every 4 days or more
Constipation/dry stools
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 twice
get up for night urine 3 times
get up for night urine 4 times
get up for night urine 5 or more times

53. Do you perspire a lot?

53.1 What is your sweating pattern like? (Time, Location, Quantity):

54. 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?

- Is it sharp or dull pain?

- How is it aggravated or relieved?

- Is it acute pain or chronic?

55. Do you have an aversion or preference to the heat or cold? Please describe:
56. Have you ever had a sexually transmitted disease/infection?
Chlamydia
Gonorrhoea
Syphilis
Herpes
Other
None

Men's Health- please skip if this section does not apply to you

57. Are you sexually active?*
No
Yes
58. Do you experience an erection first thing in the morning?

Women's Health - please skip if this section does not apply to you

59. Do you experience any of the following:
Heavy flow
Light flow
Bleeding between periods
Missed periods
Clotting
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
60. Do you still have a menstrual period?*
No
Yes

61. Age of first menstrual period

62. Date of last menstrual period:

63. How long is your typical menstrual cycle (from beginning of one period to the beginning of your next period):

64. How many days does your period last?
65. Are you currently pregnant?*
No
Yes
I don't know
66. Are you trying to become pregnant?*
No
Yes
67. Are you currently breastfeeding?*
No
Yes

68. How many times have you been pregnant?
69. Are you currently sexually active?*
No
Yes

70. Please list your current method of contraception, if applicable

Emotions:


71. What is your reaction to stress like?

72. Have you ever experienced an anxiety or panic attack? If yes, for how long?

73. Do you have difficulty relaxing? If yes, for how long?

74. Are you able to concentrate? If yes, for how long?

75. Do you have difficulty in making decisions?

76. Do you find your memory is deteriorating?

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:

Please rate your Mental Health on a scale from 1-10:

Please rate your Spiritual Health on a scale from 1-10:

Please rate your Career Satisfaction on a scale from 1-10:

Please rate your Family Health on a scale from 1-10:

Please rate your Social Health on a scale from 1-10:

Please rate your Financial Health on a scale from 1-10:
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?
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future? *
No
Yes

Name of GP:

Clinic of GP:
May we contact your doctor to provide them with updates about your progress?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

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.

Telehealth Consultation - Patient Consent, Disclaimer and Release (The following applies to patients who are having telehealth consultations).

I hereby attest that I have requested and authorized Szenan Phua (The Practitioner) to arrange an online consultation for me with him. Via this consultation The Practitioner will assess my condition and offer advice on use of self acupressure to treat my condition at home and/or prescribe herbs. I will be responsible for finding a place to fill the herbal prescription. The Practitioner will base this assessment solely on the information provided by me to him via a patient form and the consultation itself.

I understand and agree that:

· The Practitioner’s telehealth consultation is solely based on the information provided by me and, in the absence of a physical evaluation, The Practitioner may not be aware of certain facts that may limit or affect his assessment or diagnosis of my condition and recommended treatment.

· The telehealth consultation is very different from a regular face-to-face examination and that The Practitioner is limited by the information provided by me. Accordingly, the diagnosis I will receive is limited and provisional.

· A telehealth consultation is not intended to replace a full face-to-face evaluation.

· I will not have direct contact with The Practitioner unless I decide to travel to Hamilton, New Zealand for an evaluation afterwards.

· The Practitioner is only rendering a telehealth consultation and does not assume any responsibility for my continued medical care or treatment.

· I am responsible for all the expenses related to my telehealth consultation request including, but not limited to, consultation fees, phone charges if necessary.

· My medical information will be handled with strict confidentiality, privacy and security; however, I understand there are risks associated with any electronic transfer process from one location to another.

· I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.



Disclaimer and Release

I hereby completely and irrevocably release Ji De Tang Ltd and Szenan Phua and Phua Ltd and their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the “Ji De Tang Ltd Released Parties”) of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the telehealth consultation, conclusions or recommendations provided by Ji De Tang Ltd or The Practitioner. Furthermore, I agree that the Ji De Tang Ltd Released Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.

By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.

As a condition to receiving the telehealth consultation service, I have read and acknowledge that I have given this consent of my own free will.

Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's Information
Preferred consultation location:*
Dinsdale Clinic
Zoom

Occupation:
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

Please give the name of the person who referred you if you ticked Word of Mouth/Other in the above

Name of referring GP/specialist if applicable:

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?

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?

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):

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):

4. What was the initial cause of your main complaint(s)?

5. When did it begin?

6. What makes it worse? What makes it better?

7. What have you done to try to help with this?
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:

9. Is this problem(s) aggravated by the heat or cold?
10. Has this problem(s) been medically diagnosed?*
No
Yes

If yes, what was the diagnosis?

How was it confirmed?
Blood Test (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes
X-rays (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes

Others:

11. What treatment have you received previously for this issue(s)?
12. Do you take painkillers? If yes, how often?

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?

14. What potential barriers do you foresee that would prevent you from achieving your Health Goals?

15. Do you feel it is possible to eliminate or prevent these potential barriers?

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):

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):

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):

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...):

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.):

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:

22. Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? How long have you been taking them for? Please list:
23. Do you have any metal implants in your body?*
No
Yes

24. If yes, where is the implant in your body?
25. Do you wear a hearing aid or pacemaker?*
No
Yes

26. Do you have any other artificial implants? (e.g. joint replacement, metal screws etc.)

27. Have you had any significant or recent surgeries/injuries/bone trauma/fractures or hospitalizations?
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)
Covid 19
Other

29. Do you have any allergies? If yes, please list:

30. What kind of exercise do you do, if any and how often?

31. How old is your home? years.

32. How long have you lived there for?
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)

35. Do you have any household pets? If YES, what type of pet:

Diet:


36. What is your diet like? What foods do you like or dislike?

37. Do you have any dietary restrictions? (e.g. religious, vegan/vegetarian, gluten free) If yes, please specify:

38. Do you experience problems swallowing food? If yes, please describe:

39. Based on your food intake for one day, what do you typically eat?


Breakfast:

Lunch:

Dinner:

40. What foods give you indigestion, if any?

41. Do you experience any ulcers or pain in your gums? If yes, please describe:
42. Do you smoke? If yes, how often?

43. How many cups do you drink per day of the following beverages?


Soft drinks

Alcohol

Coffee

Water
44. Are you regularly exposed to second-hand smoke*
No
Yes
I don't know

45. Do you use recreational drugs? If YES, please list which kinds, and how often:

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.
Seizures/convulsions, tremors, tics
Fainting
Dizziness/poor balance/vertigo
Numbness/tingling sensation
Headache at the top & sides of the head, migraines
Neck & shoulder tension/tightness/pain
Bitter taste in the mouth
Teeth grinding
High-pitched ringing in ears
Itchy eyes
Dry eyes
Burning eyes
Bloodshot eyes
Watery eyes
Gritty eyes
Blurry vision
Decreased night vision
Floaters in the eyes
Joint pain
Rheumatoid Arthritis (also relates to spleen & kidneys)
Osteoarthritis (also relates to spleen & kidneys)
Difficulty adapting to stress
Mood swings
Depression
Anger
Frequently frustrated
Irritability
None of the above
47. Spleen/Stomach (Pancreas): Please select 'none of the above' if none apply.
Type 1 Diabetes (also relates to heart, liver, kidneys & endocrine system)
Type 2 Diabetes (also relate to heart, liver, kidneys & endocrine system)
IBS
Crohn's Disease
Ulcerative Colitis
Low appetite
Abdominal bloating
Stomach Pain
Nausea
Vomiting
Heart Burn/acid reflux
Gas
Celiac Disease
Gall Bladder removed
Haemorrhoids
Loose stools/Diarrhoea
Undigested food in stools
Alternating diarrhoea & constipation (also relates to liver, colon & small intestine)
Abrupt weight gain
Weight gain
Abrupt weight loss
Weight loss
Gurgling noises in stomach
Bleeding, swollen/painful gums
Frequent belching/hiccups
Frequent/constant hunger
Bad breath
Canker sores in the mouth
Whole body feels heavy
Dry/cracked lips
Upper row tooth pain
Weakness/atrophy in muscles
Muscle twitching/cramping/spasms
Muscle Pain
Sugar cravings
Fatigue after eating
Sleepy after meals
Bloated after meals
Worry a lot
Anxious (also relates to Heart)
None of the above
48. Lungs/Colon
Shortness of breath
Stuffiness
Sinus infections
Sinus pain
Nosebleeds
Hay fever
Runny nose
Frequent colds/flu
Acne
Skin disorders
Psoriasis
Eczema
Hives
Skin itching
Skin rashes
Skin redness
Changes in moles
Cough
Chest congestion
Wheezing
Asthma
COPD (chronic obstructive pulmonary disease)
Sputum (phlegm)
Sore throat
Trouble swallowing
Bottom row tooth pain
Sadness
Crying/weeping
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)
High Cholesterol (also relates to the spleen and liver)
Hyperthyroid (also relates to spleen, liver, kidney & endocrine system)
Autoimmune thyroid condition (also relates to spleen, liver, kidneys & endocrine system)
Heart Disease
Heart Murmurs
Inability to focus (ADD, ADHD)
Heart Attack
Tight sensation in the chest (also relates to the lungs)
Angina/Chest Pain
Chest pain traveling to shoulder
Heart palpitations (feeling your heart beat)
Heart fluttering
Irregular heart beat
Fast heart beat (above 100 beats/min)
Slow heart beat (below 50 beats/min)
Bruise easily (also relates to spleen)
Feel cold all the time - whole body
Cold Hands/Feet
Sores on tip of the tongue, speech problems
Trouble falling asleep
Trouble staying asleep
Frequent dreams
Sleep apnea (also relates to lungs)
Sleepwalking
Sleep paralysis (also relates to liver)
Blood Clotting Disorder
Waking up unrefreshed, tired
Speech problems
Mental sluggishness/fogginess
Heavy head
Anxious (also relates to spleen & stomach)
Not very happy in general
Never happy at all
Hypothyroid (also relates to spleen, liver, kidneys & endocrine system)
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
Hearing problems
Lack of bladder control (incontinence)
Wake during the night at least once 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 libido
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
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)
Loose stools
Watery stools
Diarrhoea
Passing stools with burning sensation
Bowel movements -once daily
Bowel movements - twice daily
Bowel movements - 3 times daily
Bowel movements - 4 times or more daily
Bowel movements once every 2 days
Bowel movements once every 3 days
Bowel movements once every 4 days or more
Constipation/dry stools
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 twice
get up for night urine 3 times
get up for night urine 4 times
get up for night urine 5 or more times

53. Do you perspire a lot?

53.1 What is your sweating pattern like? (Time, Location, Quantity):

54. 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?

- Is it sharp or dull pain?

- How is it aggravated or relieved?

- Is it acute pain or chronic?

55. Do you have an aversion or preference to the heat or cold? Please describe:
56. Have you ever had a sexually transmitted disease/infection?
Chlamydia
Gonorrhoea
Syphilis
Herpes
Other
None

Men's Health- please skip if this section does not apply to you

57. Are you sexually active?*
No
Yes
58. Do you experience an erection first thing in the morning?

Women's Health - please skip if this section does not apply to you

59. Do you experience any of the following:
Heavy flow
Light flow
Bleeding between periods
Missed periods
Clotting
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
60. Do you still have a menstrual period?*
No
Yes

61. Age of first menstrual period

62. Date of last menstrual period:

63. How long is your typical menstrual cycle (from beginning of one period to the beginning of your next period):

64. How many days does your period last?
65. Are you currently pregnant?*
No
Yes
I don't know
66. Are you trying to become pregnant?*
No
Yes
67. Are you currently breastfeeding?*
No
Yes

68. How many times have you been pregnant?
69. Are you currently sexually active?*
No
Yes

70. Please list your current method of contraception, if applicable

Emotions:


71. What is your reaction to stress like?

72. Have you ever experienced an anxiety or panic attack? If yes, for how long?

73. Do you have difficulty relaxing? If yes, for how long?

74. Are you able to concentrate? If yes, for how long?

75. Do you have difficulty in making decisions?

76. Do you find your memory is deteriorating?

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:

Please rate your Mental Health on a scale from 1-10:

Please rate your Spiritual Health on a scale from 1-10:

Please rate your Career Satisfaction on a scale from 1-10:

Please rate your Family Health on a scale from 1-10:

Please rate your Social Health on a scale from 1-10:

Please rate your Financial Health on a scale from 1-10:
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?
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future? *
No
Yes

Name of GP:

Clinic of GP:
May we contact your doctor to provide them with updates about your progress?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

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.

Telehealth Consultation - Patient Consent, Disclaimer and Release (The following applies to patients who are having telehealth consultations).

I hereby attest that I have requested and authorized Szenan Phua (The Practitioner) to arrange an online consultation for me with him. Via this consultation The Practitioner will assess my condition and offer advice on use of self acupressure to treat my condition at home and/or prescribe herbs. I will be responsible for finding a place to fill the herbal prescription. The Practitioner will base this assessment solely on the information provided by me to him via a patient form and the consultation itself.

I understand and agree that:

· The Practitioner’s telehealth consultation is solely based on the information provided by me and, in the absence of a physical evaluation, The Practitioner may not be aware of certain facts that may limit or affect his assessment or diagnosis of my condition and recommended treatment.

· The telehealth consultation is very different from a regular face-to-face examination and that The Practitioner is limited by the information provided by me. Accordingly, the diagnosis I will receive is limited and provisional.

· A telehealth consultation is not intended to replace a full face-to-face evaluation.

· I will not have direct contact with The Practitioner unless I decide to travel to Hamilton, New Zealand for an evaluation afterwards.

· The Practitioner is only rendering a telehealth consultation and does not assume any responsibility for my continued medical care or treatment.

· I am responsible for all the expenses related to my telehealth consultation request including, but not limited to, consultation fees, phone charges if necessary.

· My medical information will be handled with strict confidentiality, privacy and security; however, I understand there are risks associated with any electronic transfer process from one location to another.

· I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.



Disclaimer and Release

I hereby completely and irrevocably release Ji De Tang Ltd and Szenan Phua and Phua Ltd and their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the “Ji De Tang Ltd Released Parties”) of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the telehealth consultation, conclusions or recommendations provided by Ji De Tang Ltd or The Practitioner. Furthermore, I agree that the Ji De Tang Ltd Released Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.

By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.

As a condition to receiving the telehealth consultation service, I have read and acknowledge that I have given this consent of my own free will.

Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information
Preferred consultation location:*
Dinsdale Clinic
Zoom

Occupation:
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

Please give the name of the person who referred you if you ticked Word of Mouth/Other in the above

Name of referring GP/specialist if applicable:

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?

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?

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):

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):

4. What was the initial cause of your main complaint(s)?

5. When did it begin?

6. What makes it worse? What makes it better?

7. What have you done to try to help with this?
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:

9. Is this problem(s) aggravated by the heat or cold?
10. Has this problem(s) been medically diagnosed?*
No
Yes

If yes, what was the diagnosis?

How was it confirmed?
Blood Test (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes
X-rays (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes

Others:

11. What treatment have you received previously for this issue(s)?
12. Do you take painkillers? If yes, how often?

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?

14. What potential barriers do you foresee that would prevent you from achieving your Health Goals?

15. Do you feel it is possible to eliminate or prevent these potential barriers?

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):

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):

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):

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...):

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.):

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:

22. Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? How long have you been taking them for? Please list:
23. Do you have any metal implants in your body?*
No
Yes

24. If yes, where is the implant in your body?
25. Do you wear a hearing aid or pacemaker?*
No
Yes

26. Do you have any other artificial implants? (e.g. joint replacement, metal screws etc.)

27. Have you had any significant or recent surgeries/injuries/bone trauma/fractures or hospitalizations?
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)
Covid 19
Other

29. Do you have any allergies? If yes, please list:

30. What kind of exercise do you do, if any and how often?

31. How old is your home? years.

32. How long have you lived there for?
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)

35. Do you have any household pets? If YES, what type of pet:

Diet:


36. What is your diet like? What foods do you like or dislike?

37. Do you have any dietary restrictions? (e.g. religious, vegan/vegetarian, gluten free) If yes, please specify:

38. Do you experience problems swallowing food? If yes, please describe:

39. Based on your food intake for one day, what do you typically eat?


Breakfast:

Lunch:

Dinner:

40. What foods give you indigestion, if any?

41. Do you experience any ulcers or pain in your gums? If yes, please describe:
42. Do you smoke? If yes, how often?

43. How many cups do you drink per day of the following beverages?


Soft drinks

Alcohol

Coffee

Water
44. Are you regularly exposed to second-hand smoke*
No
Yes
I don't know

45. Do you use recreational drugs? If YES, please list which kinds, and how often:

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.
Seizures/convulsions, tremors, tics
Fainting
Dizziness/poor balance/vertigo
Numbness/tingling sensation
Headache at the top & sides of the head, migraines
Neck & shoulder tension/tightness/pain
Bitter taste in the mouth
Teeth grinding
High-pitched ringing in ears
Itchy eyes
Dry eyes
Burning eyes
Bloodshot eyes
Watery eyes
Gritty eyes
Blurry vision
Decreased night vision
Floaters in the eyes
Joint pain
Rheumatoid Arthritis (also relates to spleen & kidneys)
Osteoarthritis (also relates to spleen & kidneys)
Difficulty adapting to stress
Mood swings
Depression
Anger
Frequently frustrated
Irritability
None of the above
47. Spleen/Stomach (Pancreas): Please select 'none of the above' if none apply.
Type 1 Diabetes (also relates to heart, liver, kidneys & endocrine system)
Type 2 Diabetes (also relate to heart, liver, kidneys & endocrine system)
IBS
Crohn's Disease
Ulcerative Colitis
Low appetite
Abdominal bloating
Stomach Pain
Nausea
Vomiting
Heart Burn/acid reflux
Gas
Celiac Disease
Gall Bladder removed
Haemorrhoids
Loose stools/Diarrhoea
Undigested food in stools
Alternating diarrhoea & constipation (also relates to liver, colon & small intestine)
Abrupt weight gain
Weight gain
Abrupt weight loss
Weight loss
Gurgling noises in stomach
Bleeding, swollen/painful gums
Frequent belching/hiccups
Frequent/constant hunger
Bad breath
Canker sores in the mouth
Whole body feels heavy
Dry/cracked lips
Upper row tooth pain
Weakness/atrophy in muscles
Muscle twitching/cramping/spasms
Muscle Pain
Sugar cravings
Fatigue after eating
Sleepy after meals
Bloated after meals
Worry a lot
Anxious (also relates to Heart)
None of the above
48. Lungs/Colon
Shortness of breath
Stuffiness
Sinus infections
Sinus pain
Nosebleeds
Hay fever
Runny nose
Frequent colds/flu
Acne
Skin disorders
Psoriasis
Eczema
Hives
Skin itching
Skin rashes
Skin redness
Changes in moles
Cough
Chest congestion
Wheezing
Asthma
COPD (chronic obstructive pulmonary disease)
Sputum (phlegm)
Sore throat
Trouble swallowing
Bottom row tooth pain
Sadness
Crying/weeping
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)
High Cholesterol (also relates to the spleen and liver)
Hyperthyroid (also relates to spleen, liver, kidney & endocrine system)
Autoimmune thyroid condition (also relates to spleen, liver, kidneys & endocrine system)
Heart Disease
Heart Murmurs
Inability to focus (ADD, ADHD)
Heart Attack
Tight sensation in the chest (also relates to the lungs)
Angina/Chest Pain
Chest pain traveling to shoulder
Heart palpitations (feeling your heart beat)
Heart fluttering
Irregular heart beat
Fast heart beat (above 100 beats/min)
Slow heart beat (below 50 beats/min)
Bruise easily (also relates to spleen)
Feel cold all the time - whole body
Cold Hands/Feet
Sores on tip of the tongue, speech problems
Trouble falling asleep
Trouble staying asleep
Frequent dreams
Sleep apnea (also relates to lungs)
Sleepwalking
Sleep paralysis (also relates to liver)
Blood Clotting Disorder
Waking up unrefreshed, tired
Speech problems
Mental sluggishness/fogginess
Heavy head
Anxious (also relates to spleen & stomach)
Not very happy in general
Never happy at all
Hypothyroid (also relates to spleen, liver, kidneys & endocrine system)
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
Hearing problems
Lack of bladder control (incontinence)
Wake during the night at least once 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 libido
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
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)
Loose stools
Watery stools
Diarrhoea
Passing stools with burning sensation
Bowel movements -once daily
Bowel movements - twice daily
Bowel movements - 3 times daily
Bowel movements - 4 times or more daily
Bowel movements once every 2 days
Bowel movements once every 3 days
Bowel movements once every 4 days or more
Constipation/dry stools
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 twice
get up for night urine 3 times
get up for night urine 4 times
get up for night urine 5 or more times

53. Do you perspire a lot?

53.1 What is your sweating pattern like? (Time, Location, Quantity):

54. 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?

- Is it sharp or dull pain?

- How is it aggravated or relieved?

- Is it acute pain or chronic?

55. Do you have an aversion or preference to the heat or cold? Please describe:
56. Have you ever had a sexually transmitted disease/infection?
Chlamydia
Gonorrhoea
Syphilis
Herpes
Other
None

Men's Health- please skip if this section does not apply to you

57. Are you sexually active?*
No
Yes
58. Do you experience an erection first thing in the morning?

Women's Health - please skip if this section does not apply to you

59. Do you experience any of the following:
Heavy flow
Light flow
Bleeding between periods
Missed periods
Clotting
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
60. Do you still have a menstrual period?*
No
Yes

61. Age of first menstrual period

62. Date of last menstrual period:

63. How long is your typical menstrual cycle (from beginning of one period to the beginning of your next period):

64. How many days does your period last?
65. Are you currently pregnant?*
No
Yes
I don't know
66. Are you trying to become pregnant?*
No
Yes
67. Are you currently breastfeeding?*
No
Yes

68. How many times have you been pregnant?
69. Are you currently sexually active?*
No
Yes

70. Please list your current method of contraception, if applicable

Emotions:


71. What is your reaction to stress like?

72. Have you ever experienced an anxiety or panic attack? If yes, for how long?

73. Do you have difficulty relaxing? If yes, for how long?

74. Are you able to concentrate? If yes, for how long?

75. Do you have difficulty in making decisions?

76. Do you find your memory is deteriorating?

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:

Please rate your Mental Health on a scale from 1-10:

Please rate your Spiritual Health on a scale from 1-10:

Please rate your Career Satisfaction on a scale from 1-10:

Please rate your Family Health on a scale from 1-10:

Please rate your Social Health on a scale from 1-10:

Please rate your Financial Health on a scale from 1-10:
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?
Our practitioners recommend a programme for you to do at home to support the treatment you receive at our clinic. If you consent, we will send you emails with links to videos we have made specifically to help support your treatment. You can opt out at any time. Do you consent to being emailed videos and other things in the future? *
No
Yes

Name of GP:

Clinic of GP:
May we contact your doctor to provide them with updates about your progress?*
No
Yes
May we discuss appointment times with your emergency contact?*
No
Yes

Is there anyone else who you would like to give permission for us to discuss appointment times with? If yes list them here:

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.

Telehealth Consultation - Patient Consent, Disclaimer and Release (The following applies to patients who are having telehealth consultations).

I hereby attest that I have requested and authorized Szenan Phua (The Practitioner) to arrange an online consultation for me with him. Via this consultation The Practitioner will assess my condition and offer advice on use of self acupressure to treat my condition at home and/or prescribe herbs. I will be responsible for finding a place to fill the herbal prescription. The Practitioner will base this assessment solely on the information provided by me to him via a patient form and the consultation itself.

I understand and agree that:

· The Practitioner’s telehealth consultation is solely based on the information provided by me and, in the absence of a physical evaluation, The Practitioner may not be aware of certain facts that may limit or affect his assessment or diagnosis of my condition and recommended treatment.

· The telehealth consultation is very different from a regular face-to-face examination and that The Practitioner is limited by the information provided by me. Accordingly, the diagnosis I will receive is limited and provisional.

· A telehealth consultation is not intended to replace a full face-to-face evaluation.

· I will not have direct contact with The Practitioner unless I decide to travel to Hamilton, New Zealand for an evaluation afterwards.

· The Practitioner is only rendering a telehealth consultation and does not assume any responsibility for my continued medical care or treatment.

· I am responsible for all the expenses related to my telehealth consultation request including, but not limited to, consultation fees, phone charges if necessary.

· My medical information will be handled with strict confidentiality, privacy and security; however, I understand there are risks associated with any electronic transfer process from one location to another.

· I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.



Disclaimer and Release

I hereby completely and irrevocably release Ji De Tang Ltd and Szenan Phua and Phua Ltd and their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the “Ji De Tang Ltd Released Parties”) of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the telehealth consultation, conclusions or recommendations provided by Ji De Tang Ltd or The Practitioner. Furthermore, I agree that the Ji De Tang Ltd Released Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.

By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.

As a condition to receiving the telehealth consultation service, I have read and acknowledge that I have given this consent of my own free will.

Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information
Preferred consultation location:*
Dinsdale Clinic
Zoom

Occupation:
Do you work for an ACC accredited employer?*
No
Yes

If yes, what is your employer's name?
How did you hear about us?*

Please give the name of the person who referred you if you ticked Word of Mouth/Other in the above

Name of referring GP/specialist if applicable:

ACC claim number and accident date if applicable:
Have you received any acupuncture treatments for this condition previously?*
No
Yes
Was your treatment under the same ACC number?*
No
Yes

If yes, how many sessions have you had?

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?

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):

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):

4. What was the initial cause of your main complaint(s)?

5. When did it begin?

6. What makes it worse? What makes it better?

7. What have you done to try to help with this?
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:

9. Is this problem(s) aggravated by the heat or cold?
10. Has this problem(s) been medically diagnosed?*
No
Yes

If yes, what was the diagnosis?

How was it confirmed?
Blood Test (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes
X-rays (IF APPLICABLE) if yes, please bring a copy of results to your appointment*
No
Yes

Others:

11. What treatment have you received previously for this issue(s)?
12. Do you take painkillers? If yes, how often?

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?

14. What potential barriers do you foresee that would prevent you from achieving your Health Goals?

15. Do you feel it is possible to eliminate or prevent these potential barriers?

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):

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):

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):

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...):

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.):

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:

22. Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? How long have you been taking them for? Please list:
23. Do you have any metal implants in your body?*
No
Yes

24. If yes, where is the implant in your body?
25. Do you wear a hearing aid or pacemaker?*
No
Yes

26. Do you have any other artificial implants? (e.g. joint replacement, metal screws etc.)

27. Have you had any significant or recent surgeries/injuries/bone trauma/fractures or hospitalizations?
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)
Covid 19
Other

29. Do you have any allergies? If yes, please list:

30. What kind of exercise do you do, if any and how often?

31. How old is your home? years.

32. How long have you lived there for?
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)

35. Do you have any household pets? If YES, what type of pet:

Diet:


36. What is your diet like? What foods do you like or dislike?

37. Do you have any dietary restrictions? (e.g. religious, vegan/vegetarian, gluten free) If yes, please specify:

38. Do you experience problems swallowing food? If yes, please describe:

39. Based on your food intake for one day, what do you typically eat?


Breakfast:

Lunch:

Dinner:

40. What foods give you indigestion, if any?

41. Do you experience any ulcers or pain in your gums? If yes, please describe:
42. Do you smoke? If yes, how often?

43. How many cups do you drink per day of the following beverages?


Soft drinks

Alcohol

Coffee

Water
44. Are you regularly exposed to second-hand smoke*
No
Yes
I don't know

45. Do you use recreational drugs? If YES, please list which kinds, and how often:

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.
Seizures/convulsions, tremors, tics
Fainting
Dizziness/poor balance/vertigo
Numbness/tingling sensation
Headache at the top & sides of the head, migraines
Neck & shoulder tension/tightness/pain
Bitter taste in the mouth
Teeth grinding
High-pitched ringing in ears
Itchy eyes
Dry eyes
Burning eyes
Bloodshot eyes
Watery eyes
Gritty eyes
Blurry vision
Decreased night vision
Floaters in the eyes
Joint pain
Rheumatoid Arthritis (also relates to spleen & kidneys)
Osteoarthritis (also relates to spleen & kidneys)
Difficulty adapting to stress
Mood swings
Depression
Anger
Frequently frustrated
Irritability
None of the above
47. Spleen/Stomach (Pancreas): Please select 'none of the above' if none apply.
Type 1 Diabetes (also relates to heart, liver, kidneys & endocrine system)
Type 2 Diabetes (also relate to heart, liver, kidneys & endocrine system)
IBS
Crohn's Disease
Ulcerative Colitis
Low appetite
Abdominal bloating
Stomach Pain
Nausea
Vomiting
Heart Burn/acid reflux
Gas
Celiac Disease
Gall Bladder removed
Haemorrhoids
Loose stools/Diarrhoea
Undigested food in stools
Alternating diarrhoea & constipation (also relates to liver, colon & small intestine)
Abrupt weight gain
Weight gain
Abrupt weight loss
Weight loss
Gurgling noises in stomach
Bleeding, swollen/painful gums
Frequent belching/hiccups
Frequent/constant hunger
Bad breath
Canker sores in the mouth
Whole body feels heavy
Dry/cracked lips
Upper row tooth pain
Weakness/atrophy in muscles
Muscle twitching/cramping/spasms
Muscle Pain
Sugar cravings
Fatigue after eating
Sleepy after meals
Bloated after meals
Worry a lot
Anxious (also relates to Heart)
None of the above
48. Lungs/Colon
Shortness of breath
Stuffiness
Sinus infections
Sinus pain
Nosebleeds
Hay fever
Runny nose
Frequent colds/flu
Acne
Skin disorders
Psoriasis
Eczema
Hives
Skin itching
Skin rashes
Skin redness
Changes in moles
Cough
Chest congestion
Wheezing
Asthma
COPD (chronic obstructive pulmonary disease)
Sputum (phlegm)
Sore throat
Trouble swallowing
Bottom row tooth pain
Sadness
Crying/weeping
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)
High Cholesterol (also relates to the spleen and liver)
Hyperthyroid (also relates to spleen, liver, kidney & endocrine system)
Autoimmune thyroid condition (also relates to spleen, liver, kidneys & endocrine system)
Heart Disease
Heart Murmurs
Inability to focus (ADD, ADHD)
Heart Attack
Tight sensation in the chest (also relates to the lungs)
Angina/Chest Pain
Chest pain traveling to shoulder
Heart palpitations (feeling your heart beat)
Heart fluttering
Irregular heart beat
Fast heart beat (above 100 beats/min)
Slow heart beat (below 50 beats/min)
Bruise easily (also relates to spleen)
Feel cold all the time - whole body
Cold Hands/Feet
Sores on tip of the tongue, speech problems
Trouble falling asleep
Trouble staying asleep
Frequent dreams
Sleep apnea (also relates to lungs)
Sleepwalking
Sleep paralysis (also relates to liver)
Blood Clotting Disorder
Waking up unrefreshed, tired
Speech problems
Mental sluggishness/fogginess
Heavy head
Anxious (also relates to spleen & stomach)
Not very happy in general
Never happy at all
Hypothyroid (also relates to spleen, liver, kidneys & endocrine system)
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