Acupuncture Chart
Disclaimer: In Dec 2013 Ms. Richards applied for grandfathering into the new College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario. She passed all three exams and is waiting for the College to process her application. As soon as the registration numbers come through, it will be added to her credentials. Until that time, she will carry on with her other forms of treatments utilizing all the different methods of access to the points of the body through other means like electronic acupuncture through the Indigo Machine,QXCI,nutrition, Cupping massage, LED Light Therapies, tuning forks, magnets, crystal lasers and other lasers. All of these methods can be used to relieve pain and balance stress and imbalances of the body to bring back health including mental health. These methods are effective and can be used together.

Client's Name Date of Treatment
Address City Postal Code
Fax: E-Mail:
Home Phone Work Phone
Date of Birth Occupation
Referred by Family Doctor
Reason for Treatment:
Have you had acupuncture done before? When? Where?
Under medical treatment now? If yes; please give me some details:

List of Current Medications & Supplements:

List Environmental & Drug Allergies:
Last Visit to Doctor?
Hospitalizations & Surgeries:

Headaches

Eating Pattern ie 3 meals a day? Vegetarian etc.  
Sleep Pattern

Interrupted Sleep?

  Digestive - any problems or symptoms?  
Bowel Functioning

1 - 3 a day? Constipation? Diarrhea?

  Blood Disorders?  
Stress Level High Med Low

Pregnant?  
Reproductive Problems?

  Blood Pressure  

Disclaimer: The therapist, Christine Richards, does not make any claim of replacing any medical therapy. Information exchanged during any session is confidential. The treatment has been described to me, along with the risks and I accept the outcome without holding the therapist responsible in any way. I certify that the above information is correct to the best of my knowledge. I will not hold the therapist responsible for any errors or omissions that I have made in the completion of this form.

Date: _______________ Client's Signature of Consent for Treatment: _________________________________________________ _____________________________________________________________________

Point Selection: Initial Visit

Date: Point Selection Date: Point Selection