Please bring this with you to your appointment.
Family Medical History
Is there history of any of the following conditions in the family?
Please select the closest in relation when selecting the family member that has the listed condition. Any extra family members with these conditions can be mentioned in the details box at the bottom of page.
Please ensure you fill every question in this section out as it will greatly assist with your acupuncture treatment.
Please select all of the following symptoms that you have experienced in the past 6 months. Please note that some questions may be asked a number of times throughout the different Chinese Medicine diagnostic categories. We kindly ask that if you do experienced this symptom then please select it each time it is asked.
Details of Your Last Menses
Day 1 of Menses:
Day 2 of menses:
Day 3 of menses:
Day 4 of menses:
Day 5 of menses:
Day 6 of menses:
Day 7 of menses:
ART (Assisted Reproductive Technology)
Details of Sperm
I hereby request and consent to the performance of the following on myself by the licensed acupuncturists and Chinese medicine practitioners who now or in the future, treat me while employed by, working or associated with Spring Acupuncture, Fertility and Pregnancy Clinic.
Acupuncture and other Chinese medical procedures including diagnostic techniques such as listening, pulse evaluation, palpation on a variety of areas of my body, observation, range of motion, muscle and orthopaedic testing; modes of manual or physical therapy such as bodywork, structural alignment of joints and/or viscera, heat and/or cold therapy, electric or magnetic stimulation, cupping and/or moxibustion; the prescription of herbal medicines as well as dietary supplements; dietary recommendations; exercise advice and healthy lifestyle recommendations, and the performance of bodywork therapy.
I am hereby informed that the aforementioned treatment methods are all generally safe but there are some side effects or risks to treatment. I understand that although these risks are very unlikely to occur from a trained and AHPRA registered practitioner, they are possible. I understand that these risks include, but are not limited to:
Acupuncture may potentially cause temporary bruising, swelling, bleeding, numbness and tingling, or soreness at the site of needling. Highly unlikely risks of acupuncture include lung puncture (pneumothorax), nerve damage, organ puncture, and infection - although Spring Acupuncture, Fertility and Pregnancy Clinic uses only sterile, disposable needles and maintains a clean and safe environment according to government infection controlguidelines. Potential risks of moxibustion include blistering, burns, and scarring. Common side effect of cupping and guasha are temporary bruising and redness lasting a few days. Cupping can also cause blistering of the skin in some instances. The herbal and nutritional supplements (which may be from plant or mineral sources) recommended to me by my practitioner are generally safe in the traditionally recommended doses. Possible side effects of herbs include nausea, gas, stomachache, diarrhea, and headache. Unusual side effects of herbs include vomiting, rashes, hives, and tingling of the tongue. I understand I must stop taking any herbs and notify my acupuncturist if I experience any discomfort or adverse reaction.
I understand that I can discuss risks and benefits further with my practitioner before signing if I so choose, although I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on the practitioner to exercise his or her judgment in my best interest during the course of treatment, based upon the facts then known.
I understand that I am to notify the practitioner if I have an infectious disease, are a haemophiliac, have an existing heart condition, have a pacemaker, are on blood thinning medication, are pregnant, suffer from epilepsy/suffer from seizures, or have any other condition I feel the practitioner should know about.
Please be aware that all information is strictly confidential, and any information you wish not to be recorded should be indicated to the practitioner. By selecting the, 'I agree' box below, I hereby declare that all information that I have provided is accurate and truthful to the best of my knowledge.
Photo Release Form
We often get current and previous patients sending us their beautiful family and new born pictures. Our Spring Acupuncture community loves to share in these moments on our social media pages and within the clinic (eg. photo wall) and to permit this, we ask that you sign a photo release form to allow us to use only those photographs that you send to us for such use.
I grant Spring Acupuncture, Fertility and Pregnancy Clinic, the authority to use my photographs that I send to them in print or electronically. I authorize Spring Acupuncture, Fertility and Pregnancy clinic to use and publish the same in print and/or electronically.
I agree that Spring Acupuncture Fertility and Pregnancy Clinic may use such photographs of me and my family without identifying names and for any lawful purpose, including for example, such purposes as social media, publicity, illustration, advertising, and Web content.
CANCELATION & RESCHEDULING POLICY CLIENT AGREEMENT
Please read the following agreement carefully and sign below.
We understand that there are times when you will need to cancel and/or reschedule our appointment. We are pleased to accommodate your needs.
Due to the increase demand for our services we are implementing a cancellation fee and/or rescheduled appointment take place at a free appointment within 48 hours of the date of your originally schedule appointment.
If you are unable to fulfil these requirements or you miss a booked appointment, 50% of your schedule service fee will be charged and an account issued.
By signing this agreement, you are acknowledging your commitment to improving your health and wellbeing and showing respect to your healthcare provider for their time and effort.
Thank-you for your understanding.