Where patient is under 16 years old, details and consent of parent or guardian:
Proof of ID provided?YesNo
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/anginaYesNo
Blood pressure problemsYesNo
Epilepsy/seizuresYesNo
Haemophilia/blood clotting disordersYesNo
Blood borne virus, e.g. Hepatitis B/C or HIVYesNo
Skin complaints, e.g. psoriasis, eczemaYesNo
DiabetesYesNo
Allergic response, e.g. anaesthetics, jewelleryYesNo
Do you regularly take any blood-thinning medicines, e.g. aspirin?YesNo
Do you take any regularly prescribed medication?YesNo
Do you take any supplements?YesNo
Could you be pregnant?YesNo
Have you had any plastic surgery or implants?YesNo
Details of any associated problems with previous acupuncture treatmentYesNo
DETAILS - If you have entered YES above please give any details:
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
