DR. CHUN-KAI WANG, D.TCM 15532 92A Ave, Surrey, BC, V3R 9B1 604 832 3568 ------------- PRELIMINARY 1st-TIME PATIENT INTAKE FORM The confidentiality of this form will be honoured. No third party will have access without your authorization ---------------- Name: Address: Phone(cell/primary): Email: Profession: Weight: Height: Date of Birth: Male/Female If Female, are you currently pregnant: Y/N If Yes, please state time since pregnancy:____ Are you currently breast feeding: Y/N First consult date: Chief Complaint: Current BP: History of: Stroke: Y/N if Yes, occurrence: Heart Attack: Y/N if Yes, occurrence: Epilepsy/Seizure: Y/N if Yes, occurrence: Allergies(rashes, etc): Heart Disease: Y/N Pacemaker: Y/N Diabetes: Y/N type:1/2 Hepatitis: A/B/C/D/E HIV/AIDS: Y/N Respiratory(COPD, asthma etc): Y/N if Yes, explain: Blood disorders(hemophilia, low platelet etc): Y/N if Yes, explain: Other:___ Any surgeries in past 5 yrs: Y/N If YES,explain___ Medical findings in past 5 yrs: Existing/Prior drug usage: Y/N used for: Existing/Prior supplement(including Chinese herbs) usage: Y/N Any unpleasant drug/herb interactions or experiences: Y/N How is your: Bowel movements? daily? how many times: daytime urination: nigh time urination: digestion: sleep: menstruation: on time? how many days? issues with sense organs: head issues: chest issues: abnormal sweating? ------ PATIENT CONSENT TO TREATMENT This Consent to Treatment Agreement outlines the two main modalities used by the Doctor, acupuncture and Chinese herbal medicine. Acupuncture involves insertion of single-use pre-sterilized disposable needles which eliminate risks for hepatitis B, C and HIV contamination. Acupuncture side-effects may include mild local pain or bruising at needling sites after acupuncture. In very sensitive and unique individuals, headaches, dizziness, and possibly fainting for those new to acupuncture may occur. Pneumothorax is an associated risk with acupuncture which should be extremely rare if performed by a licensed Acupuncturist or if needles are completed avoided in the thoracic area. You are aware of what acupuncture is prior to your visit so this will not be explained again to you during your clinic visit. The Doctor is not authorized to make official Western Medical diagnoses of any disease, and will, in his best abilities, tell the patient to refer to the family physician if circumstances require. However, the Doctor will not be held responsible for any new diagnoses after herbal and acupuncture treatment, as it is impossible to say if this was a result of the Doctor's treatment, the natural progression of disease for which TCM was not able to control, or a preexisting disease unbeknownst to the patient prior to the time of TCM consultation. Therefore it is the patient's right to choose the treatment method he/she desires and also his/her responsibility to bear the consequences, whether positive or negative, of such treatment(s). The patient understands there is a charge of $20 for late or unnotified missed appointments without prior notice of at least 12 hours, to be paid before future treatments can begin. The patient will be rejected for future treatment for occurrences of over 2 occasions. Any remaining prepaid visits will not be refunded. Should the patient purchase the 4 treatment package it is understood that it is valid for 3 weeks from the date of purchase, after which time it will no longer be valid. Unused visits will not be credited back and continued visits will be charged at the current standard per treatment fee applicable at the time. I understand there are no refunds for the services and treatment packages given under this consent. This consent shall cover my current and any future treatments indefinitely. At any time this form may be given additions, be it new consents, clauses, terms, etc., which may have the power to override certain or all parts of this agreement provided the patient's new signature is given in the new addition(s). Clinic Visit Rules during Covid 19 For your safety and our safety, please take note of and follow the following clinic guidelines prior to and during your visit. 1. must have face MASK at all times(regular non-surgical/hospital/medical use face covers such as modified bandanas, handkerchiefs, etc. are not allowed)., if at any time is taken off, we can refuse treatment right away and patient will be escorted out 1.5 goto drwang.ca/facemask.png for example of allowed face mask 2. urinate in your home before coming 3. you will be asked to sanitize your hands and have your temperature checked before entering, if your temperature exceeds 37 C then you will not be permitted to enter and should go consult MD for further checkup if required 3.5 no shoes permitted inside the clinic; therefore please leave your shoes outside the entrance prior to entering 3.6 wear clean clothes for your visit 3.7 wear a clean and new face mask for your visit 4. no touching things, keep your hand exposure to things inside clinic to minimum 4.05. only one person may be allowed in at one time, family members included unless they serve as supporting persons(physical support, translation support, etc.) 4.1 put your personal belongings only inside the treatment room 5. our clinic follows set guidelines and protocols stringently and is covid-free so if after you visit our clinic and are later tested for covid 19 you absolve us of blame or any ties 6.prior to ypour visit you must be sure with 100% certainty that you do not have any coughing, fever, history of near-term outside travel outside lower mainland, no history of near term of being in congregations of 10 people or more, no sore throat, no aches and pains throughout whole body, no sudden onset of fatigue, no headaches outside of what you may have chronically, loss of taste or smell, no skin rash, no toe or finger discoloration as of recent, no sudden onset of conjunctivitis, no diarrhea, no dryness of throat 7.you are aware of what acupuncture is and we keep in-clinic communication to a minimum 8.Due to the seriousness of the issue the following clause may offend certain individuals. Covid-19 is a serious public health threat to everyone and we reserve the right to protect ourselves, the clinic and patients coming to see us by refusing to take certain individuals as patients or terminate treatment/visits prematurely if we feel it is unsafe to treat such individuals in close contact. Reasons may include refusal to wear face masks during treatment, not believing in Covid-19 as an actual health threat, thinking Covid-19 is not real, believing the government has blown the pandemic out of proportion, engaging in overly frequent social gatherings, not wearing face masks in social settings or in public, and/or any other reason which we deem is unsafe to work with such individuals. Note this includes new patients who have not come as well as patients who have come and are in the middle of treatment. This is neither a human rights issue nor discriminatory against certain people, but is instead a public health issue where the greater health of more people takes precedence over the case of one person. We are not forcing our viewpoints onto any people so please seek other healthcare professionals if you cannot agree with this. 9. no refunds for treatment, if you come and for whatever reason we cannot proceed with treatment or have to terminate treatment prematurely, no refunds are provided. This is because prior to your visit, intake has already been done and that already counts as consultation which is within the treatment itself. 10. intake of your health history is done online or over the phone, download the form here and fill it out and sign it and send back to us before you come, we will do further email or phone communication if required so that in-clinic communication is kept to minimum Herbal medicine:(may or may not apply, disregard if this does not apply to you): Herbal treatment includes the use of raw herbs and/or GMP herbal extracts. Herbal treatment is mostly a safe and stable form of therapy, but may elicit possible responses in certain patients with unique sensitivity, which may or may not occur. These include but are not limited to sweating, diarrhea, allergy-like rashes, etc. Patients should communicate with the Doctor if such events arise so appropriate actions are taken. Patients concurrently taking medications should space away taking of herbs from medications by 1-2 hours to avoid any possible side-effects. By writing the date and giving my signature below, I proclaim I have read the above, asked all relevant questions and understood the terms. Directly typing out the patient's full name below and sending from the patient's email address will serve the same as hand written signature. DATE: PATIENT NAME(PRINT): PATIENT SIGNATURE: PATIENT GUARDIAN/REPRESENTATIVE SIGNATURE(IF UNDER 19 YR OLD and/or PATIENT UNABLE TO PERSONALLY PROVIDE CONSENT): Legal Relationship to Patient: PATIENT GUARDIAN/REPRESENTATIVE NAME(Print):_____________ CONTACT TEL: