Hr.ADITHIYAA (Prakash.

R)
M. Acu
AKSHAYA ACUPUNCTURE
#259, 7th Main, 3rd Cross, behind Siddivinayaka Temple ,
Lalithmahal nagar,Mysore-570028.
( A Unit of Meridian Acupuncture Academy).
Email: mysoreacupuncture@gmail.com.
Web:
Mobile: +91-9449637296

Patients ID No:…………………………….

Patients Health History Form

(Please take the time to fill this form out as thoroughly as possibly. An accurate diagnosis and treatment is dependent on the information provided)

Name (Full form) ________________________________________________________________ Date ________________

Address street _______________________________________________________________________________________
__________________________________________________________________________ Pin code _________________
Phone home _________________________________ cell
____________________________________________________
E-mail _____________________________________________________________________________________________
Birth date ____________________ age _______________ height _______________ weight ________________
Occupation _____________________________________ Nature of Work ______________________________________

Responsible Party (if you are not patient)

Relationship to patient:_____________________________________________________
Name of Responsible Party:_________________________________________________
Phone: ______________________
Address: ________________________________________________________________
City:__________________________________________ Pin:_________________

Current Health Practitioners-

Please list your physicians or other healthcare practitioners.

1………………………………………………………………………………………..Phone:………………………………………….

2………………………………………………………………………………………..Phone:………………………………………….

3………………………………………………………………………………………..Phone:………………………………………….

Patient Medical Condition

When and where did you last receive health care? For what reason?
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
……

Reason for visit

What is the main reason for which you are seeking treatment?

How long ago did this problem begin?

Past Medical History (Please include date)

Significant Illnesses (please circle all applicable)

Diabetes Hepatitis High Blood Pressure Heart Disease Seizures

Stroke Thyroid Disease Cancer

Other Diagnosis:
_____________________________________________________________________________________________

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Do you have a pacemaker? __________________________________________________________________________
Do you have any allergies? _________________________________________________________________________

Surgeries or Significant Traumas

Type
1._____________________________________
2._____________________________________
3._____________________________________
4._____________________________________
At what Age
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Family Medical History:

(Please tick all applicable)
Asthma Cancer Diabetes High Blood Pressure Heart Disease Seizures Stroke

Any Others:………………………………………………………………………………………………………

For whom in the family: ………………………………………………..

Daily Habits:
Do you have a regular exercise program? If so,what? ______________________________________________________

Do you smoke? If so,how much? _____________________________________________________________________

How much milk, coffee, tea or soda do you drink per day? __________________________________________________

How much water do you drink daily? ___________________________________________________________________

How much alcohol do you drink per day?________________________________________________________________

Please describe your average daily diet below

Please list all medications you are currently taking or within past 2 months:

Medication Name Dose Condition treated

Please list over-the-counter medications, vitamins, and supplements you are currently taking:
Name Dose Reason

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Comments
Briefly tell me of any other problems you would like to discuss.

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What other kinds of treatment have you tried and for what disease/disorder?

Type Disease/Disorder

_____________________________ ________________________________

_____________________________ ________________________________

_____________________________ ________________________________

Pain History Sheet:

If your presenting complaint involves pain, please consider the following features concerning the pain:

1.Onset (how did the pain first start - suddenly, gradually? What were you doing?):

2.Main site of pain (please tick in the body picture below):

3.Radiation (does the pain move or spread anywhere? If so, where?):

4.Character of pain (sharp, dull, burning, throbbing, aching, lancinating etc):

5.Severity of pain (mild, moderate, severe, worst pain imaginable):

6.Duration of pain episodes (minutes, hours, days, weeks, months):

7.Frequency of pain episodes (once, twice, three times … per … hour, day, week, month):

8.Special times of occurrence:

9.Aggravating factors:

10.Relieving factors:

11.Associated symptoms:

Please indicate on the diagram below the site of your pain, and / or other symptoms.

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.

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 Consent to Treatment

I, ____________________________________, voluntarily consent to be treated with acupuncture and adjunct therapies

relevant to my diagnosis and treatment like cupping, moxibusion, varma massage and bloodletting.

I have been informed of the risks and symptoms of treatments, which can include, but are not limited to: slight pain, vomiting,
excess urination, dysentery, excess sweating, re-occurrence of previous pains, tiredness, giddiness, and the possibility of
other unforeseen risks. I freely accept the risks involved with my procedure.

I understand that I must let my practitioner to know if I am carrying, or believe to have any infectious agents, including but at
not limited to HIV, TB and Hepatitis. In some cases where cross-infection is high, my practitioner may withhold treatment.

I have been informed that I have the right to refuse any form of treatment. I understand the nature of the treatments, have
been informed of the risks and possible consequences involved with these treatments, and have been given the opportunity
to ask questions pertaining to the treatments. I also understand there is always a possibility of an unexpected complication
and I understand that no guarantee can be made concerning the results of acupuncture treatment. The length of my
treatment depends on the severity of my condition. In some cases my symptoms may temporarily worsen before they begin
to improve.

I ……………………………………………………………….have discussed the content of this form with my practitioner. I

acknowledge that I have asked any questions I may have and received answers I understand. By signing this form, I give my
informed consent for Acupuncture and adjunct treatments.

Signature of patient/guardian _______________________________________

Name of patient/guardian __________________________________________
Date: _______________________

Akshaya Acupuncture Policies:

• Your health is important to us,so we work with you to ensure that you are able to complete a full course of treatments and
achieve the best results.
• We strive to provide the highest level of service. Failure to cancel with sufficient notice denies an opportunity for another
Patient to be seen at the time reserved for you.
• Please arrive on time to get the full value out of your treatment. Your appointment time has been reserved for your
treatment
and I work hard to not keep patients waiting long. To respect the time of patients with appointments after yours, I will not
allow
your appointment to run late because you arrived late. Please be punctual so I can be punctual.
• Do not brush your tongue on the day of visit for treatment.
• Consume food one hour prior to visit.
• Female shall not visit during their menstruation period, can visit only if problem related with menstruation.
• The patients shall strictly follow the food restriction or any other restricted activity as recommended by the acupuncturist.
• Patients shall strictly abide by the follow-up date and time because to maintain efficacy in treatment.
• Patients shall bring all the health records of past and present health problems while visiting for treatment. (such as lab
reports,
scans, x-rays or any other reports found relevant).

Please hand this directly to the acupuncturist at your first consultation. Thank you.

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The World Health Organisation proposed that acupuncture can be used in the treatment of the following conditions

Acne Eczema Otitis Media

Addictions Enuresis Painful Periods

Allergies Frozen Shoulder Palpitations

Allergic Rhinitis Gastritis Paralysis

Anaemia Gum Problems Peptic Ulcer

Angina Haemorrhoids Polyuria

Anxiety Hay Fever Postnasal Drip

Aphasia Headache Rheumatism

Arthritis Hiccup Rhinitis

Asthma Hypertension Sciatica

Back Pain Impotence Shock

Bowel Problems Incontinence Sinusitis

Bells Palsy Indigestion Skin Problems

Bronchitis Infertility Sore Throat

Candida Albicans Influenza Sports Injuries

Catarrh Insomnia Sprains

Childhood Illnesses Lumbago Tennis Elbow

Common Cold M.E. Tenosynovitis

Conjunctivitis Menopausal Problems Thrush

Constipation Menstrual Problems Thyroid Conditions

Cough Migraine Tinnitus

Cystitis Morning Sickness Tonsillitis

Dental Pain Nausea Trigeminal Neuralgia

Depression Neck Stiffness Urinary Retention

Diarrhoea Nervous Problems Urogenital Problems

Dizziness Nosebleeds Urticaria

Drug Addiction Obesity Vertigo

Duodenal Ulcer Oedema

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Acupuncture: I understand
that the acupuncture will be
performed by the insertion
of sterile, disposable single-
use needles through the
skin at certain points on my
body; and that such
treatment is intended to
improve the body's
physiologic function or
modify the perception of
pain. I have been informed
that although rare, side
effects may result from my
acupuncture treatment.
These could include, but are
not limited to: minor pain or
discomfort, localized
bruising, fainting, nausea,
and the temporary
aggravation of preexisting
conditions.

Moxibustion: Heat
treatments using Artemesia
vulgaris (moxibustion,
“moxa”). Indirect
moxibustion treatments
involve putting moxa on the
head of the needle or on top
of a barrier such as salt or a
slice of ginger. The heat
generated from the moxa
treatments may involve
slight discomfort or leave a
blister or scar on the skin.
With any type of heat, there
is always the risk of burn.

Varma Therapy: A Indian

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ancient massage technique
on certain varmam points
on the body using
medicated oil. The
treatment leaves redness
and oil on the skin that can
lasts few hours.

Cupping: is a technique uses

glass/plastic cups under
vaccum is used to promote
circulation of qi (energy)
through the meridians. Cups
may produce a red/purple
color on the area treated
lasting 1-7 days.

Bloodletting: alone or in
conjunction with cupping,
may be used to improve
circulation in specific
meridians. Sterile needles
are inserted into the skin
and a small amount of blood
is expressed from the
puncture.

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