Men s Fertility Date:

Transcription

1 Men s Fertility Date: Last name / First name / Circle: Mr. Dr. Birth date / Age / Circle # f preferred cntact Address/ Phne (hme)/ City / Phne (wrk) / Prvince / Pstal Cde / Phne (cell) / / Occupatin / Height / Weight / Emergency Cntact / Reasn fr Visit / Family Physician name / Family Physician phne / Western Medical diagnsis (if applicable) / Have yu had Acupuncture befre? Chinese herbal medicine? Yes N Yes N Other medical treatment received (circle) / Fertility clinic Physitherapy Massage Naturpathy Chirpractic Other: Please indicate with a P (past) C (current) F (family) if any f the cnditins belw apply: Heart cnditins Strke High bld pressure Lw bld pressure Diabetes Deep vein thrmbsis Neurlgical cnditin Spinal r head injury Respiratry cnditin Kidney disrder Cancer Hepatitis HIV / AIDS Sprain/strain/fracture Osteprsis Headaches/migraines Jaw pain Arthritis Dizziness/fainting Cntagius illness Skin cnditin Digestive prblems Haemphiliac Wear a pacemaker Lung cnditin Epilepsy Upcming surgeries On the figures belw, please circle the areas f cncern/pain ; Sensatins/pain characteristics (check): Sharp Burning Mving Tingling Dull Severe Stabbing Shting Thrbbing Numbness What relieves the pain (ice, rest, activity, massage, heat )? What aggravates the pain (weather, heat, cld, rest, activity )? Please list any prescriptin medicatin r ver the cunter drugs currently taking: Please list herbal medicine and ther supplements currently taking: Please list any allergies (fd, drugs, envirnmental, etc.): Have yu been hspitalized and/r treated fr any infectius/serius cnditins r surgeries? If yes, briefly explain fr what cnditin r reasns and the year (belw). D yu use the fllwing? If s hw ften? Cigarettes: Alchl: Drugs: Cffee: Pp: D yu participate in the fllwing physical activities? If s, please indicate hw ften: Yga: Running: Fitness Class: Gym: Biking: Swimming: Walking: Other: Hw did yu hear abut Acubalance? (Internet, Friend, Dctr, Fertility Clinic, Seminar, Magazine, TV, News) Please print, cmplete, and fax in frms befre yur initial appintment. Thank yu. 1 f 6

2 Fr each symptm belw that yu currently have, rate its severity frm 1-5 (5 being wrst). Leave blank if N / A. Gan Irritability / frustratin / impatient Depressin Stress Emtinal eating Unfulfilled desires Visual prblems / flaters Blurred visin / pr night visin Red / dry / itchy eyes Headaches / Migraines Dizziness Feeling f lump in thrat Muscle twitching / spasm Neck / shulder tensin Brittle nails Sighing Sensatin r pain under rib cage Genital itching / pain / rashes Xin Palpitatins Chest pain / tightness Insmnia / sleep prblems Restless / easily agitated Vivid dreams Lack f jy in life Frgetful Aversin t heat Bitter taste in muth Tngue / muth ulcers / cankers Shen Frequent urinatin Bladder infectin Lack f bladder cntrl Wake t urinate Feel cld easily Cld hands / feet Night sweats / ht flushing Lw sex drive High sex drive Lss f head hair Hearing prblems Crave salty fd Fear Pr lng term memry Ankle swelling Tinnitus Fei Dry cugh Cugh with Phlegm Nasal discharge / drip Sinus infectin / cngestin Itchy / painful thrat Dry muth / thrat / nse Skin rashes / hives Snring Grief / sadness Shrtness f breath Allergies / asthma Weak immune system Alternate fever / chills Pi Heaviness in the head / bdy Fatigue / after eating Difficult getting up in mrning Water retentin Muscular tired / weak Bruise easily Unusual bleeding (stl, nse, etc) Bad breath Pr appetite Increased appetite Crave sweets Pr digestin Nausea / vmiting Blating / gas Hemrrhids Cnstipatin Lse stl Alternate cnstipatin / lse Abdminal pain Intestinal pain / cramping Heartburn Pensive / ver-thinking Overweight Fggy mind Yeast infectin Aversin t cld Cld nse Increased thirst Prefer warm / cld drinks Sweat easily Besides fertility, list yur main health cncerns in rder f imprtance t yu: On a scale f 1-10, hw wuld yu rate yur daily energy level (10 being best)? Are yur bwel mvements regular? Hw many times per day/week? Are they frmed, lse, cnstipated, r d they alternate frm lse t difficult t pass? Hw many times in yur life have yu taken Antibitics (apprx. #)? Hw many times have yu taken ral sterids? Please describe in general what yu eat, and what d yu crave? (sweet, spicy, salty, rganic, wheat, dairy, meat, veggies, fruit, pasta, sandwiches, sups, etc.) D yu experience urinary frequency, urgency, burning, dribbling, retentin? What clur/shade f yellw is it? D yu have a histry f urinary tract infectins? D yu have truble falling asleep? Are yu a light sleeper? Hw many hurs per night? D yu have vivid dreams? If s, what are they abut? Wake and have difficulty falling back t sleep? Hw many glasses f water d yu drink in a day? If yu were asked t describe yurself frm an emtinal standpint, what wuld yu say (i.e. irritable, wrrier, anxius, sad, impatient, stressed, etc.)? Please print, cmplete, and fax in frms befre yur initial appintment. Thank yu. 2 f 6

3 Name f spuse r partner: Hw lng have yu and yur partner been trying t cnceive? Are yu currently underging assisted reprductive treatments (IUI, IVF, ICSI, supervulatin, etc.)? Yes If yes, at what fertility clinic? N Hw is yur sexual energy/libid? Belw nrmal Nrmal Have yu had a recent physical exam? Yes N D yu r did yu have an undescended testicle? Yes N Have yu ever been diagnsed with a variccele? Yes N Have yu ever had any urlgic surgeries? Yes N Have yu experienced erectile dysfunctin? Yes N Have yu experienced difficulty ejaculating? Yes N Have yu been expsed t any envirnmental txins r hrmnes? Yes N Have yu experienced any penile discharge? Yes N D yu regularly experience ncturnal emissin? Yes N D yu have high chlesterl? Yes N Have yu had a high fever in the past 6 mnths? Yes N D yu currently have any prstate cnditins? Yes N D yu have r have yu ever had urinary infectins r STDs? Yes N Have yu ever taken teststerne supplements/drugs? Yes N Have yu recently had yur teststerne levels checked? Yes N Have yu been diagnsed with small r sft testes? Yes N Have yu been checked fr a blckage f yur reprductive tract? Yes N Have yu had any fertility testing? Yes N If yes, what was yur sperm cunt? Lw Nrmal Cunt: What was the sperm mtility? Lw Nrmal Ntes: What was the sperm mrphlgy? Abnrmal Nrmal Ntes: Other cmments: Please print, cmplete, and fax in frms befre yur initial appintment. Thank yu. 3 f 6

4 Occupatin: In the space prvided, please explain what yu d, duties invlved, and stress levels. Persnal Stress: What are the persnal and prfessinal stresses in yur life? Hbbies and Passins: What makes yu happy? What health-related gals wuld yu like t achieve with yur treatment at Acubalance? What d yu think is the cause f yur fertility issues, and what wuld fix them? Circle, highlight, r underline the terms r phrases in the right clumn that accurately describe aspects f yur character. Please take sme time, think critically, and be hnest. Kidney yang vacuity Lack f will pwer r assertin that prpels and targets the majr episdes f life Fear Paralyzed by the unknwn Passive Easily cntrlled by thers Take blame Feel guilty Large sense f respnsibility Sexual anxiety Kidney yin vacuity Irritable Fidgety Jumpy Chatty Effrt t cnceal anxiety Flighty Restless Frget names Hastily say unintended wrds Lack f tranquility Dread f death Sexual anxiety Liver qi stagnatin Feel stuck r frustrated Hit a wall Blcked Emtinal tensin Stress Easily annyed Grumpy Lwer jia damp-heat The pssibility f transfrmatin becmes the burden f unfinished business Excess wrry Feel trapped by many gd pssibilities Many unfinished prjects Cannt make clear distinctins Care fr thers but nt self Heart spleen qi & bld vacuity Frgetful Anxiety with situatins and peple Shyness Withdrawing Feel vulnerable Awkwardness Frget the wrds yu are meaning t say Frget rutine things Restless Tightness Jumpy Pr self-esteem General inapprpriate presence f tensin Pr mtivatin Lack f excitement Bred Despndent Avid activities that were nce pleasurable Nt interested in the wrld Nt engaged in creative transfrmatin Please print, cmplete, and fax in frms befre yur initial appintment. Thank yu. 4 f 6

5 Patient Infrmatin and Cnsent Frm Please read this infrmatin carefully, and ask yur practitiner if there is anything that yu d nt understand. While acupuncture, Chinese Medicine and ther treatments prvided by this clinic have prven t be highly effective in crrecting cnditins and maintaining verall well-being, practitiners are required t advise patients that there may be sme risks. Althugh practitiners cannt anticipate all the pssible risks and cmplicatins that may arise with each individual case, yu shuld be aware that the fllwing side effects can ccur. If there are particular risks that apply in yur case, yur practitiner will discuss these with yu. What are the pssible side effects f acupuncture? Drwsiness can ccur in a small number f patients, and if affected, yu are advised nt t drive; Minr bleeding r bruising can ccur frm acupuncture; In less than 3% f patients, symptms may becme wrse befre they imprve fr 1-2 days fllwing treatment. This is usually a gd sign. Please advise yur acupuncturist if wrsening f symptms cntinues fr mre than 2 days; Fainting can ccur in certain patients, particularly at the first treatment; Is there anything yur practitiner needs t knw? Apart frm the usual medical details, it is imprtant that yu let yur practitiner knw: If yu have ever experienced a fit, faint, r ther dd detached sensatins; If yu have a pacemaker r any ther electrical implants; What are the pssible side effects f Chinese Medicine and ther treatments prvided at this clinic? Bruising (lks like a circular hickey) is a cmmn side effect f cupping; The herbs and nutritinal supplements frm plant, animal and mineral surces that have been recmmended are traditinally cnsidered safe in the practice f Chinese Medicine, althugh sme may be txic in large dses r inapprpriate during pregnancy. If yu have a bleeding disrder; If yu are taking anti-cagulants (bld thinners) r any ther medicatin; If yu have damaged heart valves r have any ther particular risk f infectin. Statement f Cnsent I cnfirm that I have read and understd the abve infrmatin, and I cnsent t having treatments and prcedures frm this clinic. I have read the pssible risks f treatment utlined abve, but d nt expect the practitiner t be able t anticipate and explain all pssible risks and cmplicatins f treatment. I als understand that I can refuse treatment at any time. I wish t rely n my practitiner t exercise judgment during the curse f treatment which, based upn the facts then knwn, is in my best interests. I understand the practitiner may review my medical recrds and lab reprts, but all my recrds will be kept cnfidential and will nt be released withut my written cnsent. By vluntarily signing belw I shw that I have read this cnsent t treatment, have been tld abut the risks and benefits f treatments prvided by this clinic, and have had an pprtunity t ask questins. I intend this cnsent frm t cver the entire curse f treatment fr my present cnditin and further cnditins fr which I seek treatment. Privacy Plicy The infrmatin received and cllected abut ur clients/patients frm their visit t Acubalance is strictly private and cnfidential. It is used and viewed nly by the healthcare prfessinals and staff emplyed by Acubalance, unless, in the best interest f the client/patient, a practitiner determines that there is a need t cmmunicate with anther persn r healthcare prfessinal utside f Acubalance (als, Acubalance will nt give, share, sell, r transfer any persnal infrmatin t a third party unless required by law). Under abslutely n circumstances wuld this cmmunicatin happen withut the signed cnsent f the client/patient. The client/patient infrmatin will be stred bth in digital and hard cpy frmat n Acubalance premises. On ccasin, Acubalance may use client/patient infrmatin t cnduct clinical studies t help us imprve upn services prvided. Appintment Plicy Welcme t Acubalance Wellness Centre. We are delighted t have yu as a patient and lk frward t prviding yu with the highest quality care. In rder t ptimize yur relatinship with us, please take a minute t read ur appintment plicy. Many f ur clients are pleased t find ut that we are usually n time. This is because a treatment rm has been reserved fr yu, whereas mst medical ffices verbk by appinting several patients at the same time. That kind f scheduling prvides the practitiner with a steady flw f patients but des nt respect the patient s time. Occasinally, there is a prblem with patients wh are nt used t staying n schedule themselves. With that in mind, if yu are ging t be mre than 15 minutes late, please call t cnfirm availability. A 24 hur ntice fr cancelled r rescheduled appintments is necessary in rder t avid the cancellatin fee. This allws us time t schedule anther patient that wuld als benefit frm treatment. This appintment plicy allws us t develp a mutual cnsideratin and respect fr ur time and yurs. Print name in full Signature Date (Print name f representative if represented by anther) (Signature f Representative) Please print, cmplete, and fax in frms befre yur initial appintment. Thank yu. 5 f 6

6 Patient Infrmatin Release Request Frm I, (please print name) understand that as part f Acubalance Wellness Centre s effrt t prvide me with the highest standard f integrated care, they may cnsult freely with ther physicians and healthcare prfessinals, whse care I am under, regarding any f my medical treatments r relevant infrmatin. This culd include the exchange f bth verbal and written cmmunicatins (including lab wrk). I give full cnsent s that Acubalance Wellness Centre may share persnal infrmatin and my cnfidential treatment plan with my ther healthcare prviders t better my care. (Initial) (t be filled ut by yur Acubalance practitiner) The fllwing is an authrizatin t prvide Acubalance Wellness Centre with the fllwing infrmatin: All recent lab wrk results All medical recrds All semen tests Other: Medical Services Plan (MSP) #: Dctr s Name: Clinic Name: Clinic Phne #: Clinic Fax #: I am nineteen years f age r lder: Yes N Client/Patient Signature: Date: Signature f parent r guardian (if applicable): Thank-yu fr yur prmpt attentin t this request. Please send infrmatin by fax t If yu have any questins, please feel free t cntact us. Acubalance Wellness Centre Ltd. Please print, cmplete, and fax in frms befre yur initial appintment. Thank yu. 6 f 6