Consultation form Name * First Name Last Name Email * Phone * Country (###) ### #### Postcode * Age * Next of Kin and Phone number * Do you have Epilepsy, a Pacemaker or are you Pregnant? * Yes No Have you had acupuncture before? * Yes No Please list the reason(s) you want acupuncture and give as much detail as possible * Please give details of each complaint, for example- when did it start, symptoms, what makes it better or what makes it worse. Please give details of medication you are taking for each complaint also * Please list any other medication or supplements you are currently taking? * Any other medical history? * Please highlight which best describes your sleep * Good Poor Deep Light Less than 6hrs 7hr 8hr 8hr plus Please continue to describe your sleep * Difficulty falling asleep Wakes due to pain Wakes due to dreams Wakes due to urination Difficulty getting back to sleep Do you snore? * Yes No Please highlight which best describes your energy in the morning? * Wake refreshed Wake Tired Feel ok after tea/coffee Please highlight which best describes your energy throughout the day? * Lots of energy Tired in the afternoon Always tired How would you best describe your concentration/memory/focus Poor Good Excellent Does your feet swell as the day progresses/do you suffer from swollen ankles? Do you regularly suffer from fluid retention? Yes Strongly Disagree Disagree Neutral Agree Strongly Agree No Strongly Disagree Disagree Neutral Agree Strongly Agree Do you suffer from excess sweating? * Yes Strongly Disagree Disagree Neutral Agree Strongly Agree No Strongly Disagree Disagree Neutral Agree Strongly Agree sweat Strongly Disagree Disagree Neutral Agree Strongly Agree tears Strongly Disagree Disagree Neutral Agree Strongly Agree blood Strongly Disagree Disagree Neutral Agree Strongly Agree question Date MM DD YYYY test do you yes no maybe Thank you!
