Client Form

Name

Sex Sex Male Female

Year of birth (YYYY)

Home suburb

Contact number

Emergency contact person

Their number

How did you find out about this clinic How did you find out about this clinic Friend/family recommendation Ads Professional referral Other

Their name

Their number

Clinic Website Google True Local Natural Therapy Pages Yellow Page

Professional referral name

Professional referral number

Please tell us how you find out about our clinic

Your occupation

Medical insurance Medical insurance No Yes

Insurer name

Recent visit to doctors

Current medication

Previous acupuncture Previous acupuncture No Yes

Previous acupuncture when (YYYY/MM/DD)

Previous acupuncture by whom

Your main complaint / symptoms & current health history, including medical examination

Relevant past health history (tick all relevant items): Relevant past health history (tick all relevant items): anxiety / panic attack depression epilepsy hyper tension sinus / hay fever asthma diabetes heart problem injury skin problem back / neck / shoulder pain digestive problem hepatitis A/B/C menopause smoker cancer drug user HIV / AIDS operation T.B. Others (please specify):

Relevant family health history

You are allergic to

Clinic Clinic Calamvale Loganholme

Do you have pains? Do you have pains? No Yes

According to the diagrams above, tick all areas where you currently feel pain: According to the diagrams above, tick all areas where you currently feel pain: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30