This form does need to be filled out before your health check regardless of whether or not you are an existing patient.

PLEASE NOTE: If we were to go through these questions with you in person, it would take around 30 minutes. After that, we go through further tests (such as pulse, face, palm, ear, tongue diagnosis or thermal scan) followed by a discussion of the findings and recommended treatment plan.

By filling this form, you save around 30 minutes of our time which we would otherwise need to charge you for, resulting in significant savings to you. That is why we created this detailed form; all the questions on this form are questions we would otherwise ask in the initial exam. Now you can answer all these online without any cost.  After that your in person exam will just take 30 minutes and cost only $40.  If you are an ACC patient, your surcharge will remain the same for each treatment, but you will receive a longer initial treatment due to the time saved by filling this form in online.

If you have any trouble with the form, please call reception on 07 846 7956 or reply to this email for assistance. Thank you for your patience.

 

First Name*
Last Name*
Email*
Mobile Phone Number*
Home Phone Number
Work Phone Number
Address*
1) Date of birth* (dd/mm/yyyy)
2) Gender*
3) Occupation
4) Marital Status
5) Name of GP
6) GP Clinic
7) Next of kin, name
8) Next of kin, contact phone number
9) We may contact your doctor to provide them with updates about your progress.
10) Do you work for an ACC accredited employer? (if "Yes" go to "9", if "No" go to "10")
11) What is your employer’s name?
12) How did you hear about us?*
13) Name of person who referred you if your answer above is "Word of Mouth" or "GP/specialist referral" or "Other".
14) What is your preferred payment method?
Main Complaints
If you could get rid of any health problems what would you want to get rid of?  Please list & we will let you know if we can help.
15) What is the main complaint you are seeking help with at our Centre of Balance?
16) Average intensity: On a scale of 1 to 10, please rate the average intensity of your main complaint (0 = no discomfort,10 = extreme discomfort)
17) Intensity at worst:On a scale of 1 to 10, please rate the intensity of your main complaint at its worst (0 = no discomfort,10 = extreme discomfort)
18) What was the initial cause of your main complaint?
19) When did it begin?
20) What makes it worse?
21) What makes it better?
22) What have you done to try to help with this?
23) How does this problem interfere with your daily activities?
24) If above is "other", please list
25) What is the second main complaint which you are seeking help with at Centre of Balance? (If you don't have 2nd complaint, please go to "46")
26) Average intensity: On a scale of 1 to 10, please rate the average intensity of your second main complaint (0 = no discomfort,10 = extreme discomfort)
27) Intensity at worst: On a scale of 1 to 10, please rate the intensity of your second main complaint at its worst (0 = no discomfort,10 = extreme discomfort)
28) What was the initial cause?
29) When did it begin?
30) What makes it worse?
31) What makes it better?
32) What have you done about this?
33) How does this problem interfere with your daily activities?
34) If above is "other", please list
35) What is your third main complaint which you are seeking help with at Centre of Balance? (If you don't have 3rd complaint, please go to "46")
36) Average intensity: On a scale of 1 to 10, please rate the average intensity of your third main complaint (0 = no discomfort,10 = extreme discomfort)
37) Intensity at worst: On a scale of 1 to 10, please rate the intensity of your third main complaint at its worst (0 = no discomfort,10 = extreme discomfort)
38) What was the initial cause?
39) When did it begin?
40) What makes it worse?
41) What makes it better?
42) What have you done about this?
43) How does this problem interfere with your daily activities?
44) If above is "other", please list
45) Are you interested in
46) Are you here visiting us, because you
47) If other, please let us know the reason you visiting us.
ACC Claim Information
Only fill out this section if your case is related to an ACC claim
48) Is your condition related to an ACC claim?
49) What is your ACC claim number? What was the date of the accident?

If you don't have it with you, please provide it to our receptionist before your first appointment.
50) Have you received any ACUPUNCTURE treatments for this condition previously?
51) Was your treatment under the same ACC number?
52) If yes, how many sessions have you had?
53) Have you received treatment of any kind for this condition previously
54) If yes, what sort
Type: Ph = Physio, Os = Osteopath, Chi = Chiropractor or .....
55) Was there anything you were not happy about with that treatment?
56) What aspects were you most happy with?
Expectation and Safety
For your safety and protection and for our information, please answer the following questions relevant to you:
57) If we were to sit down and discuss your life 3 years from now and look back at today, what would have to have happened for you to be happy with your progress?
58) What potential barriers do you foresee that would prevent you from achieving your Health Goals?
59) Do you feel it is possible to eliminate or prevent these potential barriers?
60) How important is it for you to resolve your health concerns?* (Rate on a scale of 1-10 (1 being lowest, 10 being highest):)
61) Do you feel that you are coachable and would enjoy a mentor in helping you?* (Rate on a scale of 1-10 (1 being lowest, 10 being highest):)
62) Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?* (Rate on a scale of 1-10 (1 being lowest, 10 being highest):)
63) Why is it important to you that you get rid of your injury/problem as soon as possible? *
64) Do you have any metal implants in your body? (e.g. joint replacement, metal screws etc.) If yes, where is the implant in your body?
65) Do you wear a hearing aid or pacemaker?
66) Do you have any allergies? If yes, please list: (Food, Medications, Pollen, etc)
Signs/Symptoms
IMPORTANT: Complete these documents as thoroughly as possible, please be honest with yourself. Some of the questions that follow may seemunrelated to your condition, BUT they may play a major role in diagnosis and treatment. By taking this part you will have an idea how your conditions relate to the organs according to Chinese Medicine. All information is strictly confidential.
67) Heart / Small Intestine (Pituitary Gland) Physical & Emotional Signs*
(Please select "none of the above" if none apply. ***Remember to scroll down to check for more)
68) Lung / Colon Physical & Emotional Signs*
Please select "non of the above" if non apply.
69) Liver / Gall Bladder (Pineal Gland) Physical & Emotional Signs*
Please select "non of the above" if non apply.
70) Kidney / Urinary Bladder Physical & Emotional Signs*
Please select "non of the above" if non apply.
71) Spleen / Stomach (Pancreas)Physical & Emotional Signs*
Please select "non of the above" if non apply.
Your Health History and Family Health History
72) Any history of surgery or hospitalizations? and When? If yes, please list
73) If you have a current health condition, or have been diagnosed with one in the past, please list below (eg. diabetes, cancer, IBS etc...)
74) Family medical history: Please list if any of your family members currently have a health condition, or have had one in the past
(Allergies, Asthma, Arthritis, Cancer, Diabetes, Heart Disease, High Blood Pressure, Liver Disease, Kidney Disease, Anxiety, Depression, Other Mental Health Illness, Addictions/Alcoholism)
75) Other, please specify
Health Assessment and Medical Information
76) Are you taking any medications? and for how long? Include any prescription drugs, over-the-counter medication, birth control pill etc... if YES, please list...
77) Are you taking any supplements, minerals/vitamins, herbs or other natural healthcare products? and for how long? If yes, please list...
78) Have you received the following vaccinations (and Boosters if applicable)?
Dietary and Lifestyle Habits
79) How often do you exercise? (Times per week)
80) What kind of exercise?
81) Do you have any dietary restrictions? (eg. religious, vegan/vegetarian) If YES, please specify
82) Please describe what you typically eat for breakfast.
83) Please describe what you typically eat for lunch.
84) Please describe what you typically eat for dinner.
85) Please describe what you typically eat for snacks during the day.
86) Do you experience any of the following in your sleep?
87) Do you experience any of the following in your bowel movements?
Please indicate how many cups of water you drink per day based on an 8-12 oz cup?
88) Water
89) Coffee
90) Black Tea
91) Herbal Tea
92) Cola
93) Juice
94) Do you smoke tobacco? If YES, average number of cigarettes/day.
95) Are you regularly exposed to second hand smoke?
96) Do you use recreational drugs? If YES, please list which kinds, and how often.
Home Environment
97) Do you live close to any of the following?
98) How old is your home?
99) How many years have you lived there?
100) Have you done any recent renovations to your home? If YES, please describe (e.g. painting, new carpets etc)
101) Do you have any household pets? If YES, what type of pet:
Health & Wellness Levels
Health and wellness is a balance of many things. Many factors affect our lives in various ways.
These factors weave a web of health and well being.
Choose your level of satisfaction in each of the areas as the following.
For example: if you are extremely satisfied with your career, shade in the #10 in career line. 1 = Not happy, 10 = Extremely satisfied
102) Please rate your Physical Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
103) Please rate your Mental Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
104) Please rate your Spiritual Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
105) Please rate your Career Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
106) Please rate your Family Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
107) Please rate your Social Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
108) Please rate your Financial Health on a scale from 1-10
1 = Not happy, 10 = Extremely satisfied
Women's Health or Men's Health
109) Please choose one to go through: Women's Health or Men's Health.
Women's Health
Please answer from 124 to 137.
110) Do you still have a menstrual period?
111) Age of first menstrual period
112) Date of last menstrual period
113) How long is your typical menstrual cycle (days between your period)
114) How many days does your period last?
115) Are you currently pregnant?
116) Are you trying to become pregnant?
117) Are you currently breastfeeding?
118) Do you experience any of the following?*
If none of these apply to you, please check "none of the above"
119) How many times have you been pregnant?
120) Are you currently sexually active?
121) Do you suffer from low libido?
122) Please list your current method of contraception, if applicable
Men's Health
123) Are you sexually active?
124) Do you experience painful or difficult urination?
125) Do you suffer from low libido?
126) Do you experience an erection first thing in the morning?
Types of Care
According to your signs and symptoms please indicate where your current state of health falls along this Types of Care time line.
127) What type of care would you like to receive from us? *
According to your signs and symptoms please indicate where your current state of health falls along this Types of Care time line.
128) Is there anything else you would like to add that you feel is important and has not been covered?
In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of access to and correction of your personal information held by this practice. No information will be given to a third party without your permission.


Consent to Treatment

I HEREBY give my consent for acupuncture/acupressure treatment bearing in mind that a full verbal explanation has been given at the time of treatment.
I UNDERSTAND that if I choose to participate in community acupuncture, this will be done in the reception area with no privacy.
I AGREE to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
I UNDERSTAND that I have to pay for private treatments, cancellation fees and the costs of materials (splints, strappings etc.) and herbs, and any treatments declined by ACC/work insurance.
I UNDERSTAND that herbs are not refundable.
I UNDERSTAND that any unpaid bills may be referred to a debt collector and I agree that I will be responsible for the debt collection fees, and also the administration fee of $50 incurred for accounts sent to debt collection.
I UNDERSTAND that there is a 24 hour cancellation and rescheduling policy that will result in a $30 fee should I not give sufficient notice.
I UNDERSTAND that I have the right to decline part or all of the treatment offered to me at any time and I can ask for a second opinion or change my treatment provider in accordance with Section 7 of the Code of Health & Disability Services Consumer Rights 1996.
I UNDERSTAND that I can ask the staff for an explanation of treatment I am receiving at any time and that in accordance with Section 10 of the Code of Health and Disability Services Consumer Rights 1996, I have the right of complaint.

It is our policy to collect private payment for ACC treatments until the ACC claim is showing on the ACC website as being approved. We will refund the difference once the claim is approved.

Under 16s: signature, name and address of parent/guardian is required:
129) Please check the following to agree with the consent to treatment above*
130) I UNDERSTAND that there is a 24-hour cancellation and rescheduling policy that will result in a FULL PAYMENT should I not give sufficient notice.*
Please sign and date below
131) Please type in your FULL NAME for signature*
132) Today's Date*