Where patient is under 16 years old, details and consent of parent or guardian:
—Please choose an option—Proof of ID ProvidedNo Proof of ID Provided
PATIENT MEDICAL HISTORY
Do you (Does the patient, if completing for an under-16) currently suffer from, or have you (they) ever suffered from any of the following?
Heart condition/angina —Please choose an option—YesNo Blood pressure problems —Please choose an option—YesNo Epilepsy/seizures —Please choose an option—YesNo Haemophilia/blood clotting disorders —Please choose an option—YesNo Blood borne virus, e.g. Hepatitis B/C or HIV —Please choose an option—YesNo Skin complaints, e.g. psoriasis, eczema —Please choose an option—YesNo Diabetes —Please choose an option—YesNo Allergic response, e.g. anaesthetics, jewellery —Please choose an option—YesNo Do you regularly take any blood-thinning medicines, e.g. aspirin? —Please choose an option—YesNo Do you take any regularly prescribed medication? —Please choose an option—YesNo Do you take any supplements? —Please choose an option—YesNo Could you be pregnant? —Please choose an option—YesNo Have you had any plastic surgery or implants? —Please choose an option—YesNo Details of any associated problems with previous acupuncture treatment —Please choose an option—YesNo DETAILS - If you have entered YES above please give any details: I have entered any medicines, supplements and extra details in the details box above, or have none to note. I declare that the information I have provided on medical history is correct to the best of my knowledge and hereby give consent for acupuncture and / or herbal medicine to be carried out by the named practitioner. I confirm that I have been provided with information on (i) the potential complications associated with the procedure and (ii) appropriate aftercare advice for acupuncture / herbal medicine. I give consent to the practitioner to retain the details provided on this form for a period of 7 years from the last treatment I receive. I agree with declaration above
