Contact Details Contact details for each customer and a general survey about customer health related issues. Step 1 of 3 33% First Name* First Last Name* Last Your phone number*Address* Street Address Town/Suburb Postcode Email* Occupation Emergency Contact Name* Emergency Contact Number*Medical Practitioner Name First Name Date Of Birth Medical Practitioner's Phone NumberWhat Health fund are you with? Presenting ConditionsWhat is the purpose of your acupuncture / massage appointment?*e.g. general relaxation, relieve muscle tension in shoulders, legs, etc.Since approximately which date have you had this condition? DD slash MM slash YYYY What seemed to be the initial cause?What are you currently doing for your condition?What makes it better? cold heat pressure movement rest What makes it worse? cold heat pressure movement rest Check any condition that applies to you.* Abdominal discomfort Anaemia Artificial organs or limbs Birth disorders AIDS/HIV Allergies Anxiety Arthritis Asthma Chronic / Acute Pain, please list below: Chronic disease, please list below: Chronic Fatigue Syndrome, low energy level Circulation or fluid retention problem Clotting or Bleeding Contagious condition, please list below: Constipation Diarrhea Diabetes Disc problems Dizziness Ear disease Eating or weight problem Eye disease Emotional condition Fibromyalgia Glandular fever Headaches Heart disease Hepatitis Herpes High / Low blood pressure, please select below: Infectious disease, please list below: Kidney or bladder problem Liver, gallbladder problems Lungs or breathing problems Mouth, throat or dental problems Multiple Sclerosis Numbness Pacemaker Phlebitis/Varicose Veins Spleen problem Scoliosis Seizures/Epilepsy Sinus, nose congestion/problems Skin condition, please list below: Sleep Problem Stress Stroke Thyroid, please select below: Tumor/Cancer, please list below: Other, please list below: None High / Low blood pressure options High Blood Pressure Low Blood Pressure Thyroid options Hypo Hyper Do you currently use:* Alcohol Caffeine Tobacco Recreational Drugs None of the above Please indicate if you have used any of the above within last 12 months.How often is your usage?Recent experience* Hospital Accident / injury Pregnancy High drug (alcohol, cigarette etc.) consumption Prescribed medications Mental health support None Other: Please indicate if you have current or experience within last 12 months. Women Pregnant Menstruation difficulties Menopause difficulties None Other: What areas would you like to be treated if you have a massage? Back Neck, shoulders Arms & hands Legs & feet Upper gluteals Upper chest & neck Face & scalp Abdomen Other: This will be discussed at the first and any following appointments. Special information or instructionse.g. particular sensitivities, particular areas requiring focusFamily Medical History* Cancer Diabetes Heart Disease High Blood Pressure Stroke Arthritis Epilepsy Mental Illness Asthma, Hay-fever Anemia Kidney Disease Glaucoma Tuberculosis None Other Select relevant options and provide details below as necessary. How did you find out about Jacqueline Thomas Acupuncture & Massage?* Word of mouth Referred by health service Poster / business card Internet search Other Terms & Conditions I have honestly and comprehensively answered the above questions. I understand that acupuncture treatments involve the insertion of sterile, disposable needles at several points in the body and methods of treatments include the following, depending on the Jacqueline’s judgment: Use of acupuncture to stimulate acupuncture points and meridians Use of an electro-acupuncture device to stimulate acupuncture points and meridians Swedish and/or Tui Na massage Use of moxibustion Acupressure Cupping Gua Sha Dietary advice Auricular ear acupuncture Herbal medicine I understand that the administration of acupuncture could directly or indirectly result in adverse effects to my body including, but not restricted to: light-headedness, minor bleeding, bruising, soreness, pain and general relaxation. I understand that although precautions are made to avoid any medical complications, I will be responsible to seek further medical attention. My health details will be discussed with Jacqueline before treatment begins. Jacqueline will determine a therapeutic strategy appropriate to my needs and within the therapist's scope of practice; Jacqueline will discuss with me instructions about acupuncture and massage procedures, areas of the body to be treated, draping and undressing procedures and positioning options during the treatment; Prior to treatment being confirmed, a physical examination may be required which could include partial undressing and the therapist palpating (touching) me; I can propose alterations to the treatment plan at any stage during the treatment; I can end the treatment at any time and accept there may be financial consequences If I have any questions or concerns, I will seek further information and discuss my concerns with Jacqueline. I have stated all my medical conditions and will keep Jacqueline updated on my health. It is my responsibility to notify Jacqueline if any information provided in this document changes. If at anytime during the session I feel uncomfortable and/or wish Jacqueline to adjust pressure, draping, or room temperature etc, I will tell her so. I wish to proceed freely and voluntarily with such treatment and I give my permission for Jacqueline to proceed. * I agree to the terms and conditions:
