abacupuncture.com.au€¦ · web viewit is not intended to diagnose, treat, cure, or prevent any...

Welcome to our practice,

We are healthcare practitioners embracing the philosophy, art and science of traditional medicine to maximise health, prevent illness, maintain wellbeing and increase fertility of couples to create healthy pregnancies and ‘better’ babies. To enable us to assist you with your health goals, would you please take the time to complete this form to the best of your ability prior to your first appointment. Please do not take any supplements for 2 meals before your first evaluation and bring any supplements with you that you are currently taking.

Health and Wellness Assessment (IVF) Date:

Full Name:

Address: Postcode:

Phone: (H) (W) (M)

Email Address:

Age: Date of Birth: Occupation:

Height: Weight:

Blood Group:

Marital Status: Spouse’s name: Children:

Health Fund: Who told you about us?

Emergency Contact: Phone:

Medical Doctor/ Obstetrician/ Midwife:

Phone:

Would you like to be added to our mailing list?

Andrea Bicket Acupuncture& Natural Fertility Management

11/175 Ocean Drive, Twin Waters QLD 4564Ph. 0418 506 678

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Have you experienced Acupuncture or seen a Naturopath/Nutritionist before? Yes/NoMain Complaint:

IVF pictureHow long have you been trying to fall pregnant?

Why have you chosen to use IVF? Any known reasons for not falling pregnant naturally?

Have you had IVF before: □ Yes □ No

How many fresh cycles?

How many frozen cycles?

How many eggs harvested? 1st 2nd 3rd 4th 5th 6th 7th 8th

How many eggs frozen? 1 2 3 4 5 6 7 8

Did eggs get to blastocyst stage?

Any successful cycles? □ Yes □ No

Date of the last IVF cycle:

Date of next IVF cycle:

Have you had your hormones tested? □ Yes □ No

Were the results normal? □ Yes □ No

If NO please specify:

What other tests have you had? Were there any abnormal results? If yes, what were they? Has your partner’s sperm been tested □ Yes □ No

If Yes was the result within the normal range? □ Yes □ No

If NO please specify



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Past Medical History: Have you ever had any of the following diseases or conditions? Please highlight and date.

Cancer/Tumours Diabetes

Hepatitis/Liver problems Cardiovascular Disease/Symptoms

Glandular Fever Thyroid Disease/Hormonal disorders

Seizures/Epilepsy/Neurological disorders Venereal Disease/HIV

Sinus Trouble/Hay fever Respiratory problems

Low energy levels

Or any other conditions that you feel are relevant…

Please list any medications you are currently taking and how long you have taken them:

Name: Length of Use: Dose:

Please list any supplements you are currently taking and how long you have taken them

Name: Length of Use: Dose:

List and date any surgeries, broken bones, scars:

List any other significant trauma:



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Your typical dietPlease fill out the following food diary in as much detail as possible.

List any

allergies or intolerances:

General Health

Please highlight anything that is relevant to your health at the moment:



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Day 1 Day 2 Day 3

BreakfastTime:

Food(s): Food(s): Food(s):

Morning TeaTime:


LunchTime:


Afternoon TeaTime:


DinnerTime:


Desert / Evening snack Food(s): Food(s): Food(s):

Beverages

Sleep Cannot Too much Vivid dreams

Can't get to sleep

Can get to sleep but can't stay asleep

Awake 1-3am, can't get back to sleep

Awake 3-5am, can't get back to sleep

Wake to urinate

Headache Frequenc-y? Daily weekly monthly

Front Back Left Right Top All over Triggered by?

Appetite Strong Weak Average Little appetite but you eat because you know you should

No appetite

Favourite flavours? Sweet sour salty bitter

Thirst Strong thirst

Weak thirst

Have to put the fire out drink heaps

Alcohol, if so, about how much

Fruit juice/soft drinks

Coffee/ tea Water Consume 1.5Lt plus per day because it’s good for you?

Digestion Bloating Heartburn Nausea Vomiting Pain Reflux BurpingBowels More than

twice daily

Daily Skips days

Every 2-3 days

Once a week

Nausea before a motion

Pain before a motion

Loose / soft

Hard Formed Easy to pass

Difficult to pass

Don’t feel fully evacuated

Foul smell Gas

Dark Brown

Light brown

Black Greenish Brown

Whitish Blood Mucous

Chest Heavy Difficulty breathing

Pain Palpitatio-ns (racy heartbeat)

Anxiety tightness

Phlegm Cough

Perspiration Easily with strenuous exercise

Easily without exercise

At night With chills With hot flushes

Very little Not at all

Skin Lesions Puffy Dry Oily Itchy Dandruff Eczema, Psoraisis

Acne

Nose Blocked Runny Bleeds Hay fever Sinusitis Adenoids Removed

Eyes Red eyes Sore eyes Itchy eyes Wear glasses or contact lenses

Had laser eye surgery

Cataracts Glaucoma Poor night vision

Ears Ringing Poor hearing

Pain Excessive wax

Recurrent infection

Gromets

Throat Always tender

Occasionally tender

Tender and painful now

Very rare Dry Tonsils Removed

Urination Copious A little Associated discomfort

Sense of urgency

Dark colour

Frothy Foul smell Incontinen-ce

Stiffness Neck Shoulders Mid back Lower back

Hips Legs Arms All over

Numbness Neck Shoulders Mid back Lower back

Hips Legs Arms



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Dizziness Upon exercise

Upon rising

With movement

No pattern

Quality ofPain / Discomfort

DullNaggingache

Debilitating severe pain

Searing pain on movement

Pain regardless of movement

Pain interrupts sleep

Discomfort worse upon rising in the morning

Continuou-s unrelenting pain

Location of Pain / Discomfort

Head Neck shoulders arms

Mid back Lower back

Hips Leg / legs Chest Abdomen

Energy Always low

Fluctuates

Not enough

Easily tired Lots of nervous energy

Unable to relax

Emotion Angry Sad Depressed

Anxious Grief Irritable Fluctuating moods

Stress High Moderate Low Don’t cope well with stress

Menstruation Pain / PMT

Clotting Regular Irregular Associated with constipati-on

Loose stool with onset of period

Associated with loss of energy

Associated with headaches

Additional Questions. Please provide your thoughts belowWhat have you tried to improve your health (professional help, treatments, diets)?



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For our time together to be considered a win, what do you want to take place on this program? Is there a time-frame for your outcome?

Do you feel your health concerns/symptoms have a purpose, in that it could be your body letting you know it needs some help and there are changes and shifts that needs to be made? Explain your thoughts.

What may prevent you from making the necessary lifestyle changes needed to improve your health?

List your current 3 highest priorities (values) in your life. Where does your health fit in?

Thank you for your time and consideration

Informed Consent to Naturopathy

At Health and Wellness Acupuncture we use gentle non-invasive techniques in order to determine the best approach to support your health and wellbeing using nutritional supplements, detoxification therapies, dietary, and lifestyle advice. During your initial



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consultation we will review your history, clarify your health goals, and make sure that the services that we offer will match your expectations. Please take the time to fill out the important questionnaire contained within this package. It is vital that you give us whole and truthful information especially concerning medications and any health conditions you may have, for example cardiovascular disease, diabetes etc. The responses you provide will greatly assist us in understanding your health goals and expectations so that we can formulate an individualised wellness plan tailored to your needs. It is important however that you understand that the ultimate responsibility for your health care is your own, and that we are only here to support you. Our advice is not intended to replace the advice of your GP or health care provider but rather to assist the body nutritionally. It is not intended to diagnose, treat, cure, or prevent any disease.

Client Consent - I/We understand that results cannot be guaranteed and I/we do not expect the practitioner to be able to anticipate and explain all risks and complications. I/we will rely on them to exercise judgment during the course of the procedures which they feel at that time is in my best interests, based on the facts that are known. I am/we are also aware that there are some slight health risks in taking nutritional supplements. These include, but are not limited to: potential allergic reactions to supplements or herbs, some aggravation of pre-existing symptoms or the development of detoxification symptoms (headache, tiredness etc.)

I/we understand that a record will be kept of the services provided to me/us, and that it will be kept confidential and will not be released to others unless so directed by myself unless the law requires it and I/we also understand that I/we may look at my health record at anytime.

With this knowledge, I voluntarily consent to assessment and advice from the practitioner in charge of my care for the entire course of treatment for my present condition. I/we understand that I am free to withdraw my consent and discontinue participation at any time.

Date:

Name: ________________________

Signature ________________________

Informed Consent to Acupuncture and Traditional medicine

I ___________________________________________hereby agree and consent to the performance of acupuncture and other Traditional Medicine procedures. I understand that such procedures may include, but are not limited to, acupuncture, moxibustion, gua sha



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(dermal friction technique), exercise therapy, Do In (Japanese massage), Chinese or western herbal medicine, and nutritional counselling. Acupuncture is a technique utilising fine stainless steel needles inserted at specific points in the body to correct various ailments. Moxibustion is the application of heat on or over acupuncture points using compressed and ignited fibre of Artemesia vulgaris, commonly known as Mugwort. Do In (Japanese massage) is used to facilitating healing. Occasionally there may be increased soreness at the sites of treatment on the day of, or the day following treatment. I have been informed that in all acupuncture treatments, only sterile, disposable needles are used to ensure the safest acupuncture treatment possible. I have been informed that acupuncture is a safe method of treatment but may have some side effects, including but not limited to bruising, numbness or tingling, dizziness or fainting, minor swelling, and/or bleeding. A hematoma may occur at the site of insertion and may last a few days. A sensation of light-headedness may occur after acupuncture treatment. I will immediately notify the acupuncturist if I experience any symptoms or problems.I understand that I should not make significant movements while the needles are being inserted, manipulated, retained, or removed. I understand that on rare occasions moxibustion therapy may result in a burn at the site of application. I understand that I should not make significant movements while moxibustion is being applied. I will immediately inform the acupuncturist if the moxibustion feels at all uncomfortable. I am relying on the practitioner to exercise judgment and caution during the course of my treatment, trusting that, based upon facts then known, this treatment plan is appropriate and in my best interests. I understand that acupuncture and other Traditional Medicine procedures are not substitutes for treatment by my medical doctor. At any given time throughout the treatment, I may request the practitioner to stop, modify, or change the treatment plan. This is NOT a waiver form. It is part of our “duty of care” to you that we inform you of any material (pertinent) risks associated with professional treatment techniques. In very rare cases, acupuncture has been reported as being associated with bodily infections and collapse of lung. Allergic skin reactions to massage oils, acupuncture needles, or topical applications are a possibility. I understand that Andrea Bicket Acupuncture is a teaching practice and that students studying Traditional Medicine may participate or assist in my care. I understand that student participation is limited by law and is at all times under the supervision of qualified practitioner.By voluntarily signing below, I certify that I have read this form, have been informed of the risks and benefits of acupuncture and traditional medicine, and have had an opportunity to ask questions. I request and consent to acupuncture and traditional medicine care described above. I intend this consent form to cover the acupuncture care for this and future presentations.

Date:Name:Signature: Practitioner: Signature:



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