Confidential New Patient Intake Form

Confidential New Patient Intake Form - Quit Smoking
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Occupation *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Health Fund
Home Phone
Mobile (No spaces) *
E-mail *
Referred By *

Google Word of mouth Facebook TV Radio Internet Voucher Internet Smooth FM (95.3) WSFM 2UE Other
If other please specify?
If referred by a TV channel or Radio station please specify which one?
If word of mouth, who can we thank for referring you? (Full name Please)
If Internet Voucher, please specify and incude Redemption code:
Emergency Contact Name and Number
Have you had acupuncture before?
What is your height? *
What is your weight? *
Age of first menses?
Smoking History:
Please select how many cigarettes you smoke each day? *

10 or less 11-20 21-30 31 or more
Do you smoke more in the first few hours after waking up than you do during the rest of the day? *

No Yes
How soon after you wake up do you smoke your first cigarette? *

Within 5 minutes 6-30 minutes 31-60 minutes After 60 minutes
Which cigarette would you hate the most to give up? *

The first one in the morning Any other one
How old were you when you started smoking regularly? Please specify: *
How long have you been smoking at this level? Please specify: *
If you work, how much do you smoke during your workday? Please specify: *
Do you wake-up during the night to smoke? *

Yes No
Important questions:
Do you have hypertension *

Yes No
Do you have severe atherosclerosis *

Yes No
Do you have Hypersensitivity to Cytisine *

Yes No
Do you have a peptic or duodeneal ulcer *

Yes No
Do you have hypertension stage two or three? *

Yes No
Are you on medication for tuberculosis? *

Yes No
Have you had acute Myocardial infaract? *

Yes No
Do you have arrythmia? *

Yes No
Do you have unstable Angina? *

Yes No
Do you have severe bleeding? *

Yes No
Are you pregnant or breast feeding? *

Yes No
Quitting History:
Have you tried to quit before? *

Yes No
Tick if you tried? *

Cold turkey Cutting down gradually Self-help pamphlet Individual counselling Support Group Acupuncture Hypnosis Laser Nicotine Gum Nicotine Patch Nicotine Lozenge Champix Nicotine Inhaler Zyban
Other? Please provide details
Methods which you were most successful with? *

Cold turkey Cutting down gradually Self-help pamphlet Individual counselling Support Group Acupuncture Hypnosis Laser Nicotine Gum Nicotine Patch Nicotine Lozenge Champix Nicotine Inhaler Zyban
Other? Please provide details
When was your last quit attempt? *

Never tried to quit Within the last month Within the last year Over a year ago Over 5 years ago
Other? Please provide details
How long did you go without smoking that time? *

Less than 1 day 1 day to 1 week Less than 2 weeks but more than 1 week Less than 1 month but over 2 weeks Less than 3 months but over 1 month Less than 1 year but over 3 months More than 1 year
Why did you start smoking again? *

Craving to smoke became too strong Needed it to cope with pressure and stress Began smoking at a party or other social situation Began smoking while drinking alcohol
Other? Please provide details
How many times have you quit smoking for more than 24 hours? Please specify: *
What is the longest you have gone without smoking? Please specify: *
Your feelings about quitting smoking:
Importance: Tick the number that best measures how important it is for you to stop smoking (1 being not at all and 5 being very important) *

1 2 3 4 5
Commitment: Tick the number that best measures how committed you are to stop smoking (1 being not very committed and 5 being very committed) *

1 2 3 4 5
What benefits do you get from smoking? Please specify:
What harm or negative effects has smoking caused you? Please specify:
Why do you want to stop smoking? Please specify:
What makes it difficult for you to quit smoking?Please specify:
Are you concerned that your weight will be affected as you quit smoking?

Yes No
Past operations and health history : please specify:
Are you currently taking medication? Please specify:
Are you currently taking any supplements/ herbs? Please specify:
Do you have any known allergies or food sensitivities? Please specify:
What types of disease / illness do your parents have? Please specify:
Other - please specify:
Do you suffer from any of the following? *

Amenorrhea Anemia Anxiety Asthma Back pain Bladder problems Bleeding disorder Breast implants Bronchitis Cancer Celiac disease Chest pain Constipation Depression Diabetes Diarrhea Digestive problems Dizziness/Vertigo Eating disorder Epilepsy Eye problem Food/plant allergy Gallbladder problem Haemorroids Hayfever Headaches Hearing problem Heart problem High blood sugar High cholesterol High blood pressure Hepatitis HIV/AIDS Hyperthyroid Hypothyroid Infertility Irregular periods Joint replacement Low blood pressure Metal/silicon allergy Migraines Neck pain Organ transplant PCOS PMT Sinus problems Skin problems Sports injuries Weight gain Weight loss Insomnia Arthritis Brushing Disorder Coronary Heart Disease Lymphatic disorders Pituitary disorder Tinnitus None of the above
Are you on a special diet?

Yes No
If yes please specify
Do you drink alcohol?

Yes No
If yes please specify
Do you or have you done recreational drugs?

Yes No
If yes please specify
Do you exercise?

Yes No
If yes please specify
Stress levels ?

Low Medium HIgh
Please answer the following questions to help us understand you better:
Location of Pain

Head or Face Neck Chest Arms or Hands Legs or Feet
Quality of Pain

Dull ache Strong ache Sharp stabbing Searing Diffuse Specific
When Pain Occurs

With movement Without movemen All the time With heat With cold With damp Day Night
Stiffness

Neck Shoulders Upper Back Middle Back Lower Back Hips Legs Arms
Sleep

Cannot sleep Sleep too much Can't fall asleep Can't stay asleep Wake to urinate Wake from pain Night sweats Vivid dreams
Energy Level

Always low Fluctuate Tires easily Better with exercise Lots of energy Wakes tired Tired after eating Tired in afternoon
Body Temperature

Feels hot Feels cold Likes the heat Prefers cold Cold hands and feet Hot feet Likes hot drinks Likes cold drinks
Headaches

Daily Weekly Monthly Front Back Sides All over Specific trigger
Appetite

Not hungry can't eat No appetite eat anyway Average appetite Binge eating Emotional eating
Favorite Flavour

Sour Salty Sweet Bitter
Thirst

Strong thirst Weak thirst Drinks heaps Drinks Little 1L per day More than 1L per day Coffee or Tea Sweetened Drinks
Urination

Copious Frequent Scanty Pain Dark colour Night time Urgency
Bowel Movements

Once daily More than once daily Every 2 to 3 days Severe constipation Pain Loose stool Watery diarrhea Dry hard stool Urgency
Digestion

Bloating Pain Reflux Nausea Option5 Vomiting Option7 Ulcer IBS Intestinal problem
Chest

Rib pain Heart pain Palpitations Tight Short of breath Heavy Anxiety Cough
Phlegm

In throat Blocked nose Sinus congestion Post nasal drip Yellow or green Clear or white
Skin

Dry Oily Rashes Eczema Red Flaky Acne Puffy
Perspiration

Easily with exercise Easily without exercise At night With hot flushes With chills A lot A little None
Throat

Often tender Hurts in middle Hurts on sides Swollen glands Dry Stuck feeling
Ears

Partially deaf Fully deaf Hard of hearing Tinnitus Pain Frequent Infections
Eyes

Poor vision Red Dry Puffy Itchy Tired Painful
Dizziness

Upon rising in AM Upon standing With exercise With movement No pattern
Menstruation Frequency

Regular Irregular Absent Bleeding between cycles Menopause Post menopause
Menstruation Symptoms

Abdomen pain Back pain Leg pain Heavy bleeding Congealed blood Light bleeding Loss of energy Loose stools Constipation Headaches Nausea Vomiting
Please upload blood test results & letters from your specialist/GP (Max 2MB)
Is there anything else you would like to tell
Informed Consent to Treatment - I hereby agree and consent to the performance of acupuncture and other Traditional Chinese and Japanese Medicine procedures. I understand that such procedures may include, but are not limited to, acupuncture, moxibustion, cupping, gua sha (dermal friction technique), infrared heat lamp, laser, electro-acupuncture, breathing techniques, exercise therapy, Tui-Na (Chinese massage), Do In (Japanese massage), Shiatsu (Japanese massage), Chinese or western herbal medicine, and nutritional counselling. Acupuncture is a technique utilizing fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using the compressed and ignited fiber of Artemesia vulgaris, commonly known as Mugwort. Cupping utilizes round suction cups over a large muscular area (such as the back) to enhance blood circulation to the designated area. Laser uses low level radiation to stimulate acupoints. Tui Na (Chinese massage), Do In and Shiatsu (Japanese massage) are used in facilitating healing and pain management. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment. I have been informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. I have been informed that acupuncture is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A hematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if I experience any symptoms or problems. I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable. I understand that while undergoing treatment using Laser, I must always wear safety eyewear and never look directly into the Laser beam as it can damage the eyes. I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Chinese and Japanese Medicine procedures are not substitutes for treatment by my medical doctor. Also, at any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan. This is NOT a waiver form. It is part of our "duty of care" to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections or collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility. I understand that Eastern Therapies is a teaching clinic and that students studying Chinese Medicine at University may participate or assist in my treatment. I understand that student participation is limited by law and is at all times under the supervision of qualified practitioners. I understand that Eastern Therapies is a group practice and that my treatment may be completed by more than one fully qualified practitioner. I will inform my practitioners immediately of any discomfort with this arrangement and steps will be taken to modify my treatment. By voluntarily signing below, I hereby certify that I have read this entire form, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I consent to treatment with the modalities described above. I intend this consent form to cover the entire course of treatment to be performed for my present condition. I have read this form, understand the information it contains, and give my consent to treatment. *
Please type your initials in the above box agreeing that you have understood the above statement:
Full name *
Draw your signature into the box below *

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Date and time *

Month Day Year Hour Minutes AM/PM Option
Would you like to have a regular newsletter from us? *

Yes No
I have been informed that I need to provide 24 hour notice should I want to cancel or reschedule an appointment. Cancellation fees may apply if I don't give enough notice.
Please sign your initials that you have received and understand our policy *

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Confidential New Patient Intake Form - Quit Smoking

Smoking History:

Important questions:

Quitting History:

Your feelings about quitting smoking: