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Facial Rejuvenation Acupuncture Intake Form Dr. Katelin Parkinson, Naturopathic Doctor General Information Name: __________________________________ Today’s Date:_______________________ Date of Birth: ____________________ Age: _______________ Gender/Sex: __________ Full Mailing Address: _________________________________________________________ Home Phone #: ___________________________ Other Phone #: _____________________ May we leave messages on your home phone relating to your visits? ☐ Yes ☐ No Email address: ______________________________ Emergency Contact Name:____________________ Phone #: _______________________ Relation to you: ____________________ Your occupation: ____________________________ How did you hear about Facial Rejuvenation at our clinic? _________________________ Family Physician: _________________________________ Phone: ____________________ Other Health Care providers: _______________________ Phone: ____________________ _______________________ Phone: ____________________ Date of last visit: __________________ Labs or other tests performed?_________________________ Is a Naturopathic Doctor currently treating you? ☐ Yes ☐ No As a professional courtesy, our clinic may send a progress letter to your family doctor or other health care providers listed. Do we have your permission to do so? ☐ Yes ☐ No What Are Your Goals/Expectations For Treatment: ___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 1 Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-‐574-‐5151 Please describe, and indicate on the picture below, the concerns you have about your face and/or skin, in order of importance to you: 1. _______________________________________________________________________________ 2. _______________________________________________________________________________ 3. _______________________________________________________________________________ 4. _______________________________________________________________________________ 5. _______________________________________________________________________________ General Medical and Cosmetic History: The general state of your health is: excellent___ good____ avg____ fair____ poor_______ Current prescribed/over-‐the-‐counter medications (including Advil, Tylenol, antacids): Medication Dose Since when Purpose Prescribed by: Self/MD/ND 2 Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-‐574-‐5151 Current natural health products (supplements, vitamins, herbs, homeopathics): Supplement (incl brand) Dose Since when Purpose Prescribed by: Self/MD/ND Previously diagnosed medical conditions, serious illness or hospitalizations with approximate dates: ______________________________________________________________________________________ ______________________________________________________________________________________ Please indicate any cosmetic surgeries, or procedures (Filler, Botox) that you have done in the past, with approximate dates. Also indicate any CURRENT procedures you are undergoing: ______________________________________________________________________________________ ______________________________________________________________________________________ Please indicate any adverse reactions you may have had to any of the above-‐mentioned procedures: ______________________________________________________________________________________ Allergies: Medications | Environmental | Foods: ______________________________________________________________________________________ What is your current level of ENERGY from 1-‐10 (10 = best you have ever felt) ________ What is your current level of STRESS from 1-‐10 (10 = highest stress level felt) _________ What are your current sources of stress, and how do you cope? ____________________________ _____________________________________________________________________________________ Do you have a bleeding/clotting disorder? ☐ Yes ☐ No If yes, describe: ___________________ Do you bruise easily? ☐ Yes ☐ No If yes, describe: _____________________________________ Have you recently, or are you currently taking any blood-‐thinning substances (pharmaceutical or natural) ☐ Yes ☐ No If yes, describe (include brand, dose, frequency): _______________________ _____________________________________________________________________________________ Is there any chance you are currently pregnant, or are you trying to conceive? ☐ Yes ☐ No Describe your current skincare regime: ____________________________________________________ Please describe any other health issues or information, which may be helpful in our care for you: ______________________________________________________________________________________ 3 Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-‐574-‐5151 Informed Consent for Acupuncture Treatment This statement of consent pertains to the practice of Facial Rejuvenation Acupuncture (FRA) performed by Dr. Parkinson, ND. FRA, also referred to as Cosmetic acupuncture is a treatment based on the principles of Traditional Chinese Medicine, and involves the insertion of fine, sterile, disposable needles into specific areas of the face, ears, neck, hands, trunk and legs, along channels or meridians of energy. I understand that FRA and Naturopathic medical visits are separate services. I understand that I will not be receiving a full Naturopathic assessment and a Naturopathic medical diagnosis will not be made. I understand that by law, Katelin is not able to discuss or prescribe treatments for any medical conditions or concerns during cosmetic acupuncture visits; and that a separate Naturopathic visit must be booked for this purpose. I understand that any nutritional or natural supplements that are suggested during cosmetic acupuncture treatments are general recommendations that pertain to skin care. I will be told what health conditions cannot be treated adequately with acupuncture alone so that I can make an informative decision on whether to pursue another form of treatment in addition to acupuncture. Other treatments can be pursued with Dr. Parkinson, through her regular Naturopathic visits, or with another healthcare provider. Cosmetic acupuncture is contraindicated if you suffer from the following conditions: • Migraines • Diabetes • Abnormal coagulation (bleeding) disorders such as hemophilia. Constant use of: Aspirin, Fish oil, Vitamin E, certain herbal medicines • Pituitary disorders • Cancer • AIDS • Seizures or Epilepsy • Coronary heart disease • Chronic vertigo/dizziness Cosmetic acupuncture should not be administered during: • Acute herpes (cold sore) outbreaks • Acute allergic reactions • Migraine Headache • Whole body sunburn or facial sunburn • Colds or Flu (other forms of acupuncture can be done to address these symptoms) Patients with high blood pressure should consult their medical or naturopathic doctor before beginning cosmetic acupuncture treatments. Whether successfully medicated or not, this is a condition that may prevent treatment. If you are currently pregnant, think you may be pregnant, or are trying to conceive please let the practitioner know. Acupuncture is safe during pregnancy but certain points must be avoided. Potential side effects include: Pain, bruising, fainting, or injury. Puncturing of an organ is rare but possible. There may be a temporary aggravation of certain symptoms. Fatigue after treatment is common, but should subside. 4 Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-‐574-‐5151 By signing this consent form, I agree and understand that: •
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Treatment results are variable for each individual and cannot be guaranteed. Treatment plans and lengths are guidelines only and are subject to change according to individual progress. You are free to consult with any other licensed health care provider as you chose and the acupuncture treatment Dr. Parkinson provides is not exclusive, but it is important that she is informed of any other treatment you are receiving in order to avoid negative interactions/side effects You understand the fee schedule and agree to pay for all costs of visits You understand that Dr. Parkinson is not an acupuncturist and it is your responsibility to ensure that acupuncture performed by a Naturopathic Doctor will be covered under your insurance plan. To my knowledge, I ______________________________ do not have any of the contraindications listed above, and I am aware of the circumstances during which facial acupuncture should not be performed. I understand that if I am diagnosed with any of the above conditions listed as contraindications during my course of treatment with FRA that I will disclose this information to the Dr. Parkinson. By signing this consent form, I agree that I have read and understand all of the above, including the potential risks and side effects of treatment, and thereby authorize my informed consent to acupuncture treatment by Dr. Parkinson, ND. Name of patient (please print) Signature of patient Date Name of witness (please print) Signature of witness Date 5 Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4 W: www.greenbasehealth.com E: [email protected] T: 519-‐574-‐5151