English Français Acupuncture Registration and Medical Questionnaire Confidential. Required fields are marked with an asterisk. Page 1 of 2 1. Personal Information Information Last Name * First Name * Date of Birth * Sex Select... M F Height Weight Street Number Street Apartment City Province Postal Code Home Telephone Office Telephone Cell Telephone Profession Referred By Reason for Visit * 2. Medical Questionnaire Current Doctor Are you presently under a doctor's care? * Select... Yes No Specialty Last Name First Name Telephone Diagnosis Prescribed Treatment Other Doctor Have you consulted other doctors in the last 12 months? * Select... Yes No Specialty Last Name First Name Telephone Diagnosis Prescribed Treatment Other Healthcare Professionals Have you consulted other healthcare professionals in the last 12 months? * Select... Yes No Professional 1 - Specialty Professional 1 - Last Name Professional 1 - First Name Professional 1 - Telephone Professional 1 - Prescribed Treatment Professional 2 - Specialty Professional 2 - Last Name Professional 2 - First Name Professional 2 - Telephone Professional 2 - Prescribed Treatment Add a second healthcare professional Medications Currently taking anticoagulants? * Select... Yes No Currently taking corticosteroids? * Select... Yes No Currently taking prescription or over-the-counter medication? * Select... Yes No If yes, which medications? Medical History Heart problems (infarction, angina, valve problems, breathing) * Select... Yes No Cardiac stimulator (pacemaker) * Select... Yes No Blood pressure problems * Select... Yes No If yes, blood pressure type Select... High Low Both Prolonged bleeding * Select... Yes No Anemia * Select... Yes No Lung problems or tuberculosis * Select... Yes No Asthma * Select... Yes No Hay fever * Select... Yes No Allergic reaction to foods * Select... Yes No If yes, specify foods Allergic reaction to medications * Select... Yes No If yes, specify medications Stomach ulcer * Select... Yes No Liver disease (hepatitis A, B or C, cirrhosis, cholesterol) * Select... Yes No Kidney disorders * Select... Yes No Diabetes * Select... Yes No Thyroid problems * Select... Yes No Epilepsy * Select... Yes No Nervous disorders or anxiety * Select... Yes No Frequent headaches * Select... Yes No Dizziness or fainting spells * Select... Yes No Earaches * Select... Yes No Skin disease * Select... Yes No Arthritis * Select... Yes No Sexually transmitted diseases (STDs) * Select... Yes No Acquired Immunodeficiency Syndrome (AIDS) * Select... Yes No Positive diagnosis for HIV * Select... Yes No Active Implantable Medical Device (AIMD) * Select... Yes No Radiation therapy and/or chemotherapy (tumour) * Select... Yes No Pregnant * Select... Yes No Metal prostheses * Select... Yes No Joint prostheses (hip, knee, shoulder, other) * Select... Yes No Breast implants * Select... Yes No Addictions and Surgery Do you suffer from an addiction? * Select... Yes No If yes, specify Alcohol Drugs Tobacco Caffeine Other Other addiction details Have you ever had surgery? * Select... Yes No Surgery 1 Surgery 1 Year Surgery 2 Surgery 2 Year Surgery 3 Surgery 3 Year Surgery 4 Surgery 4 Year Back Next Submit Questionnaire
