Health Intake Form

Contact Information

Family Contact Information

Emergency Contact Information (If different individual from above)

Family Doctor Information

Medical History

Ongoing Health Condition

Medication/Supplement

Please check any conditions you are experiencing

(Past and Present)

This confidential information of your medical record and health history will be kept in the Easy Health TCM Clinic and will not be released to any individual except when you have authorized this release in writing or when required by law. Please complete this form as thoroughly as possible to optimize your health care outcomes.

Consent to Collect Use, and Disclose Personal Health Information

I, [the patient] consent for Easy Health TCM Clinic to collect, use and disclose my personal health information for the purpose of providing traditional Chinese medicine or acupuncture to me and for the related purposes set out in Easy Health TCM Clinic’s Written Privacy Statement. 

The personal health information that may be collected, used or disclosed by the Clinic may include the following, among other things:

• my birth date and contact information

• my health history and family health history

• my health status

• the health care I receive (including identifying my health care provider(s));

• my health number

• the identification of my substitute decision-maker, if any

• insurance or billing information relating to health care

I understand that there may be situations in which practitioners at Easy Health TCM Clinic will have to collect, use or disclose personal health information without my consent, but that they will only do this if permitted by law.

How My Information Will Be Used

I understand that my personal health information may be collected, used or disclosed for the following reasons:

• To provide me with traditional Chinese medicine or acupuncture services

• To obtain payment for services provided

• To assist insurance companies with insurance claims verification

• To seek advice for potential treatment options

• To provide or arrange health care in cases of emergencies 

• To fulfill any obligations as mandated by law

Patient Access to Information

I understand that my personal health information is available to me for my review except in limited circumstances as permitted by law. I also understand that I can ask to have my personal health information corrected if I believe there is a mistake in the records, with some exceptions. 

Acknowledgment

I allow Easy Health TCM Clinic to collect, use and disclose my personal health information as outlined above.

I understand that I can access my personal health information with some limited exceptions. 

I understand that I am not required to sign this form and that I can withdraw my consent at any time by contacting R.TCMP/R. Ac, but it may directly affect the services I can receive. My personal health information may still be collected, used or disclosed if permitted by law.

Patient Informed Consent to Treatment 

I, [the patient] consent Easy Health TCM Clinic to have the R.TCMP/R.Ac perform the following treatment within the scope of acupuncture and “Traditional Chinese Medicine” on me: 

• Acupuncture treatment involves the penetration of skin by sterile, one-time-use, disposable filiform needles;

• Assessment by the collection of data by interviewing, observation, palpation, pulse taking, tongue observation and other methods;

• Acupressure and therapeutic massage (tui-na, (Chinese massage), stone massage, shiatsu, reflexology);

• Dietary herbal supplements and Chinese or Western herbal medicine;

• Nutritional counselling;

• Energy-flow work, exercises or other prescribed forms of movement (e.g. Reiki, Qigong, Tai Chi);

• Heat therapy with the use of mugwort (moxibustion) or a heat lamp over localized areas;

• Glass cups “fire- cupping”, plastic suction cups;

• Gua sha tools for scraping;

• Electrical stimulation of acupuncture needles;

• LED (Light therapy).

I acknowledge that the R.TCMP/R.Ac has explained the following to me:

• the nature of the treatment, as set out above 

• the material risks of the treatment 

• the material side effects of the treatment 

• the alternatives to having the treatment 

• the likely consequences of not having the treatment 

  
  

I acknowledge that my practitioner cannot guarantee the results of the proposed treatment.

I acknowledge that I have informed my practitioner about my relevant health history, including whether I have any allergies, metal implants, severe heart disease, if I am currently pregnant, if I suffer from any type of major bleeding disorder, if I use a pacemaker, or if I have any infectious viruses or diseases. 

I understand that my consent is voluntary, and I have the right to withdraw my consent to the treatment at any time. 

I understand that I must lie still during treatment; have a right to refuse service at any point.

I understand that the practitioner has the right to avoid or discontinue the treatment due to the concern of customer’s constitution or health condition, which is inappropriate for the treatment.

I understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered. I acknowledge that my practitioner has explained the applicable fees to me. 

I understand that the assessment, diagnosis, and treatment of medical conditions by TCM varies from Western medicine.

I understand that there is risk of side effects, which may include:

Pain Acupuncture needling may cause an initial “prick” as it punctures the skin followed by a temporary achy sensation, numbness, or tingling at or near the needling sites that may radiate. These are all normal needling sensations and may last a few days. Please tell your practitioner if any sensation is too strong so they can adjust the treatment accordingly. Tuina (Chinese Massage), acupuncture insertion, acupuncture stimulation, electro-acupuncture, cupping, guasha, qigong (exercise), may all cause pain. Patient feedback is important for the student practitioner to adjust the treatment when necessary; Electrical stimulation of acupuncture needles produce a mild vibration/tapping sensation on the needles, which may be painful;

Bruising Bruising may occur anytime we puncture the skin. If you cannot have bruises on some area of the body, please inform your practitioner. The normal reaction of cupping and “gua sha” scraping is to leave red marks or bruising. This will usually slowly resolve on it’s own with 5-10 days and is part of the intentional therapeutic effect. Infection It is possible to develop an infection whenever the skin is punctured despite using single use disposable needles and clean needle technique. Please inform us if you have a known immune problem so we can take special precautions.

Burns & Smoke Irritation Heat therapy and moxibustion may cause redness, blistering or unintentional burns and/or scarring. It is important to verbally communicate with your practitioner if any heat therapy feels too hot. Smoke from moxibustion may cause coughing, lung irritation, headaches or allergic reactions for those sensitive to scents or smoke;

Feeling of Relaxed or Sleepy It is common to feel relaxed or sleepy after treatment so avoid getting up too quickly and rushing anywhere directly after treatment. Give yourself time to adjust after treatment before driving or using the stairs or any other potentially dangerous activity.

Dizziness & Fainting Dizziness or fainting can occur as a result of treatment. Please tell us if you are prone to fainting. Important factors that can decrease this risk include ensuring you have had sufficient food, ensuring you have not had any drugs or alcohol prior to treatment, communicating if the stimulation is uncomfortably strong, and getting up slowly after treatment.

Drug-herb Interactions Herbal dietary supplements (which are from plant, animal, and mineral sources) may have a strong smell or taste, be toxic in large doses, may be inappropriate during pregnancy and have some side effects such as uneasiness in the stomach, nausea, loose stools or other digestive reactions. If you experience such a reaction to the herbs you should inform your practitioner. Do not take herbs within two hours of taking other medications as they may interfere with each other. If you experience any adverse side effects, stop taking the herbs and contact your practitioner immediately. Severe allergic reactions are rare, however, if you experience severe allergic reactions, seek immediate medical attention. Oils, plasters, or other topical herbs may stain clothing or skin and may cause skin irritation. If the skin is irritated, reduce frequency and quantity. If irritation continues, discontinue use entirely and contact your practitioner for an alternative.

Auricular acupuncture patches need to be removed after 3 days to avoid infection;

Other unusual risks include spontaneous miscarriage, nerve damage, organ puncture, lung puncture (pneumothorax), infection, shock, complication, death and other unknown and unintended side effects;

During the course of treatments some symptoms may temporarily worsen before improving.