Download Health Assessment Form

1180 Stellar Drive, Newmarket, On, L3Y 7B9
Tel: 905-953-8088 www.lifestylesspafitness.com
CLIENT INTAKE FORM
Today’s Date: _________________________
Name: ____________________________________________________
Date of Birth: _____________________________
Address: _______________________________________________City: ____________________Postal Code: _______________
Telephone: (home) _______________________________________
(Alt) _________________________________________
Email: _______________________________________________How did you hear about us? _____________________________
Emergency Contact Name: ____________________________Relationship: ___________________Tele: ____________________
Employer: _______________________________ Occupation: _____________________________________________________
Welcome to Lifestyles. We emphasize the team approach to wellness, prevention and treatment of disease. Our purpose
is to help you achieve and maintain your health-related goals. We work together with you, that means you are invited to
participate as actively as possible in the work we do together. We provide many services which are commonly
reimbursed by typical insurance companies. Insurers vary in their rules, regarding acupuncture, massage therapy and
other modalities. Because of the changing nature of this system, private payment is necessary for our services at the time
of your visit. We will provide all necessary documentation to you in order for you to submit a claim for reimbursement
to your insurer. We look forward to becoming health partners with you.
I authorize Lifestyles Wellness Spa & Fitness Center Inc. to release information to my insurance company pertaining
to my health care in order for them to process a claim which is being submitted for reimbursement.
I am responsible for paying all fees at the time of service
I will provide Lifestyles Wellness Spa & Fitness Center Inc. at least 24 hours notice should I require to cancel an
appointment or I will be held responsible for the full service fee
I understand Herbal products and Supplements are not returnable
Acupuncture, herbal medicine, Tuina massage, nutrition and other TCM modalities are safe and effective for the
prevention and treatment of a wide range of health problems and for the promotion of general well being. Although
TCM is helpful for many health conditions, it is not intended to replace any tests or treatments recommended by your
physicians. It is advised that you inform your physician and other practitioners of your choice of various treatment
modalities so that a team approach may be employing to treat you. Please note that acupuncture and Tuina massage are
safe. Occasional bruising, and post needling sensation may happen. Fainting may occur for new patients due to
nervousness, hunger or extreme fatigue. Chinese herbs are also very safe and effective when recommended by qualified
practitioners. Occasional abdominal upset or diarrhoea may occur although this can be the response of the body to
treatment. If you have any concerns, please do not hesitate to ask.
Client Statement:
I _________________________________ (undersigned patient) herby request and consent to receive treatment from
Lifestyles Wellness Spa & Fitness Center Inc. including Traditional Chinese Medical treatments including acupuncture,
herbal medicine, medicated diets, Tuina Massage and other related treatments from the practitioners. I acknowledge that
the above treatments and all its ramifications have been fully explained to me. I also absolve Lifestyles Wellness Spa &
Fitness Center Inc. and all practitioners if I experience any unexpected effects resulting from the treatment. I further
agree to not commence lawsuit of any kind against all parties mentioned. This statement is being signed voluntarily.
Client name __________________________________
Signature ______________________________
Parent or guardian name, if under age 18._______________________________________Date _______________
1
Your Medical History: Please circle all that apply and record year:
Diabetes, High Blood Pressure, Low Blood Pressure, Anaemia, Thyroid, Cancer, HIV, Heart Disease, Intestinal disease,
Ulcers, Cholesterol, Seizures, Prostate problems, Arthritis, Infertility, Liver disease, Stroke, Addictions, Bone Density
concerns, Severe burns, Neurological or Psychological problems, Contagious disease, Other –please list.
Years Diagnosed:
_________________________________________________________________________________________________
Hereditary illness in the family _______________________________________________________________________
Please list any times of hospitalization including any surgery you have and record year:
_________________________________________________________________________________________________
Please list any medication you are currently taking (prescription or over the counter):
Medication _______________________________ Condition __________________________________Year______
Medication _______________________________ Condition __________________________________ Year______
Medication _______________________________ Condition __________________________________ Year______
Please list any vitamins, minerals, herbal or homeopathic remedies you are currently taking:
Supplement _____________________________Dose________ Condition __________________________________
Supplement _____________________________Dose________ Condition __________________________________
Supplement _____________________________Dose________ Condition __________________________________
Health care providers and other treatments –medical or holistic
Name_____________________________Telephone # ____________________ Type of care _____________________
Name_____________________________Telephone # ____________________ Type of care _____________________
Name_____________________________Telephone # ____________________ Type of care _____________________
Please list any allergies: _____________________________________________________________________________
Are you pregnant
Yes Due Date:___________________
No
Do you Smoke
Yes
No
What would you eat in a typical day?
Breakfast: ________________________________________________________________________________________
Lunch: ___________________________________________________________________________________________
Dinner: __________________________________________________________________________________________
Snacks: __________________________________________________________________________________________
How many cups: Coffee ____ Tea ____ Soft drink____ Alcohol____ Water____ Juice____ Milk_____ Other:________
Cravings: ________________________________________________________________________________________
Please list any foods you avoid and why: ________________________________________________________________
Are you a:
Meat eater
Vegetarian
Vegan
Since_________________ Reason _______________________
How often do you consume meat: ____________
Source/type of meat_________________________________
How often do you consume dairy: ____________
Source/type of dairy________________________________
Please list types of physical activity and frequency:
_________________________________________________________________________________________________
2
Please take the time to complete the form honestly and in complete detail
What would you most like to achieve through your treatments?
_________________________________________________________________________________________________
Condition: began, relieving/exasperating factors:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
General Information:

Body Temp:
PLEASE CIRCLE YOUR CURRENT SYMPTOMS
cold/warm hands/feet;
feel hot/cold/alter;
sensitive to weather change,
hot flash,
sweat easily
Part of body that sweats or experiences heat:
_____________________________________________________________________________________________________

Thirst:
increase/decrease,
prefer hot/cold fluids,
dry mouth
_____________________________________________________________________________________________________

Urine: back pain with urination or holding urine, bladder infections, Kid stones, painful or burning urine,
delayed weak stream,
frequent urine, urgent urine, small/large amount, leak,
night urine, smell,
blood
Color of urine: _________________________________________________________________________________________

B.M:
diarrhoea/constipation/alter,
urgent,
burn, itchy, mucous, pain, blood in stool
undigested food,
hard to digest fats or raw food, haemorrhoids, bulk: thin, narrow, pellets, parasites, Candida, incomplete empty,
Color of stool: ______________________________How many bowel movements each day?
_____________________________________________________________________________________________________
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Abdomen: nausea/vomit, heartburn, belch, bloat/full, gas, pain/burn/cramp/spasm, increase/decrease
appetite, stress aggravates, tired before/after meal, miss meal: confused, irritable, dizzy, poor focus, shaky, clammy
_____________________________________________________________________________________________________
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Head:
poor memory,
headaches/migraines,
faint/dizzy/fuzzy,
dull,
poor balance/coordination,
sharp/stabbing pain,
poor concentration/confused,
______________________________________________________
worse: list time of day, weather, food triggers, stiff neck _______________________________________________________
Frequency of headaches____________________________ Location of headaches:__________________________________
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Hair:
loss,
dandruff/dry scalp,
oily,
brittle, thin,
early grey,
excess/less growth
_____________________________________________________________________________________________________

Skin: fungal infections, rash, increase pigment, color –yellow, red, pale, sores, acne, poor wound healing,
white patches, bruise/bleed easily, dry/itchy, sensitive to sun, bumps on back of arms, poor tone/elasticity
_____________________________________________________________________________________________________
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Nails:
blue,
brittle/thin,
pitted,
white spots
_____________________________________________________________________________________________________
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Body
recent weight gain/loss,
swell throat/armpits/groin
feel heavy Lymph:
water retention -Location: ______________________________
-Factors: _______________________________
_____________________________________________________________________________________________________

Bones, joints, muscles:
TMJ,
calcium deposits,
poor flexibility,
better/worse exercise,
crack,
shaky,
poor posture,
numb,
weak,
muscle loss,
restless legs, cramp, twitch,
decrease height,
swelling,
aches/stiff/pain, decrease range,
List location of symptoms: ________________________________________________________________________________
_____________________________________________________________________________________________________
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
Lu & Nose:
allergies –season___________________,
frequent colds/flu -# of times past year________________
cough –dry or mucous ________________
nosebleed,
dry nose,
snore,
asthma,
nasal drip,
breath –deep/shallow, Shortness of breath,
ill with damp conditions, sinus congestion/infections -# of times past
year_________, phlegm –color _____________, noticed when_________________________________________________
_____________________________________________________________________________________________________

Chest: palpitation,
pounding, heaviness,
tender, produce milk w/o nursing
tight,
shortness of breath,
sweating, Breast:
swell,
lump,
_____________________________________________________________________________________________________

wax –Hard or Moist___________
Ears:
itchy,
infection -# of times past year_________________
hearing loss –Right or Left ________ Since ________________________________________________________________
ringing/buzzing –Right or Left ______________________ High pitch, Low pitch,
ache –when_______________________
_____________________________________________________________________________________________________

Eye:
infection,
spots/floaters,
dry/burn,
strain/pain,
heavy,
watery,
puffy,
blurry,
sensitive,
color of the whites of the eye: ___________________________________________________________________________
_____________________________________________________________________________________________________

Mouth:
dry,
Tongue: twitch,
Gums: inflamed,
hard to chew/open,
smell/taste: foul, sweet, bitter, burnt;
mouth/tongue sores (cankers)
swollen, tender, Throat: hard to swallow, swollen, sore, dry, Teeth: grind tooth decay,
bleeding, Lips: dry, sores, crack, swollen,
color of lips: ____________________________
_____________________________________________________________________________________________________

Emotions: depressed, suicidal, anxiety,
shy,
hyper, aggressive,
frightened, stress, overworked, feel stuck,
hard to carry out plans
obsessive,
restless,
irritable,
Do you feel fulfilled in your current career? ___________________________________________________________________
Are you in a positive work environment –boss, co-workers, clients? ________________________________________________
How many hours do you work each week? ___________________________________________________________________
Shift work? __________________________ Steady hours? ______________________Financial security_________________
Time to commute to work? ______________________________________________ High traffic?_______________________
Do you have support from friends/family?____________________________________________________________________
How do you handle your emotions?
_____________________________________________________________________________________________________

Energy:
exhausted,
sleepy,
sluggish,
excess,
increase/decrease with stress/exercise/caffeine/eating
_____________________________________________________________________________________________________

Sleep:
hard to fall asleep/stay asleep,
hard to fall back to sleep,
insomnia,
wake tired,
sleep apnoea
vivid dreams –types of dreams __________________________________________________________________________
How many hours of sleep do you get each night?_____________________ # of times you wake_________________________
Reasons you wake (light sleeper, hot, sweat, thinking, urinate, restless body, aches)
_____________________________________________________________________________________________________

Libido:
increase/decrease,
painful
_____________________________________________________________________________________________________

Male:
swelling groin,
painful testes,
sexual dysfunction: erectile, ejaculation,
impotence,
cold/numb
_____________________________________________________________________________________________________
Thank you for taking the time to complete the form honestly and in complete detail.
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Tongue:___________________________________________________________________________________________
Pulse: ____________________________________________________________________________________________
TCM Diagnosis: _____________________________________________________________________________________________
Treatment:_________________________________________________________________________________________
4
Female:
Age at which menses began: __________
Date of last menstrual period began ____________________
Are your menstrual cycles regular? Yes
No How many days are there from one period to the next? _________
Have your cycles changed since they began? Yes
No How____________________________________________
Do your bowel movements become lose at the beginning of your period? Yes
No
Are your periods painful?
Yes
No How long does the pain last? _____________ Medication? ____________________
How many days do you normally bleed? ___________________ How heavy is the bleed? Light
Normal
Heavy
What color is the blood? Pink
Light red
Red
Dark red
Purple
Brown
Black
Is there clotting: Yes
No
Do you ovulate on your own: Yes
No
On what day of your cycle ___________ Describe discharge color ___________, smell _________, amount _______________
2 weeks before menses:
spotting
confused/forgetful headache, location____________________________________
diarrhoea
constipation, palpitations, tired
anxiety, nervous irritable/anger/resentful depressed/hopeless
nausea, vomiting, weight gain, water retention/bloat, frequent urination, low back pain,
breast tenderness,
insomnia, increase sweat,
breakouts,
abdominal cramping
Number
Years
How many pregnancies have you had?
________
_____________________________
How many children do you have?
________
_____________________________
How many abortions have you had?
________
_____________________________
How many miscarriages have you had?
________
_____________________________
How many times has a D&C been performed? _______
_____________________________
Any problems during pregnancy, birthing or postpartum? ________________________________________________________
Date of last Pap smear _______________ Any findings past or present?____________________________________________
Have you ever had a cervical biopsy, operation, cauterization or conization? Yes
No
Have you ever had a venereal disease? Yes
No
Do you get yeast infections regularly? Yes
No Medication?______________________________________________
Have you ever been diagnosed with a chlamydial infection? Yes
No
Do you have chronic vaginal discharge? Yes
No
Do you have any sores on your genitalia? Yes
No
Have you ever had pelvic inflammatory disease? Yes
No
How was it treated?______________________________
Have you ever been diagnosed with: uterine fibroids Yes
No
polyps Yes
No
endometriosis Yes
No
pelvic adhesions Yes
No
pelvic abnormalities Yes
No
Have you ever taken any medications for gynaecological conditions other than contraceptives?
Medication _______________________________ Condition __________________________________Year______
Medication _______________________________ Condition __________________________________ Year______
Have you had fertility treatments? Yes
No
Type & When _____________________________________________
Where ___________________________________________________
Have you taken medication to help you ovulate? Yes
No When_________________ How long? ____________
Have your fallopian tubes been evaluated medically? Yes
No
Results__________________________________
Have you had tubal operations? Yes
No
Have you had any hormone laboratory test performed?
Yes
No
Results________________________________
Have you taken oral contraceptives? Yes
No When__________________________________________________
Have you ever had an IUD? Yes
No When__________________________________________________
Have you ever taken DepoProvera? Yes
No When__________________________________________________
How is your sexual energy? Low
Normal
High
Do you douche?
Yes
No With what ______________________________________________________________
Do you use vaginal lubricants? Yes
No
Are you presently taking steroids? Yes
No
Are you 20% over you ideal body weight? Yes
No
Are you 20% below you ideal body weight? Yes
No
Do you have excessive facial hair? Yes
No
Do you have excessively oily skin? Yes
No
Any excessive loss of head hair? Yes
No
Any discharge from your nipples? Yes
No
Was your mother exposed to any environmental toxins / hormones when she was pregnant with you? Yes
No
Have you been exposed to any known environmental toxins or hormones? Yes
No
Have you had a diagnosis relation to infertility? Yes
No What_________________________________________
How long have you been trying to conceive? _____________Is your partner supportive of your with to conceive? Yes
No
Menopause: date: ___________
Mammogram: date ___________ Results? ____________________________________
Today is day ______________________ in my cycle.
Thank you for taking the time to complete the form honestly and in complete detail.
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Tongue:___________________________________________________________________________________________
Pulse: ____________________________________________________________________________________________
TCM Diagnosis: _____________________________________________________________________________________________
Treatment:_________________________________________________________________________________________
5
Patient Name: ______________________________________
Age: _________
Date: ________________________
Summery:
_____________________________________________________________________________________________________
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