Patient File | cambridge

Patient Consent To Treatment

The services provided in this clinic include: herbs, acupuncture, moxibustion, cupping and dietary based on Traditional Chinese Medicine.

The side affects may occur in a small percentage of patients and may include the following: some pain following treatment in the treated area, minor bruising or bleeding, blisters after cupping, or minor infection and needle sickness (fainting). If you have a severe bleeding disorder, a pacemaker, or you are pregnant, please let the treating practitioner know prior to treatment.

By fill the personal information, select the check box "I accept terms & conditions", complete the "Medical History and Symptoms (Questions form 1 and 2)" below. I agree to receive the treatments according to the diagnosis of the TCM practitioner Rong (Lydia) Li.

**Please submit all the information above mentioned to complete this agreement (Patient Consent To Treatment)**

I accept terms & conditions

Thanks for submitting! Please complete Medical History and Symptoms (Questions form 1)

Medical History and Symptoms (Questions form 1)

Thyroids *

High

Low

Hashimoto

Bump

Normal

Urine *

Frequent

Nocturia (night time)

Uclear

Normal

Prostate

Enlarged

Prostatitis

Plastate cancer

Normal

Sweat *

Spontaneous

Night sweat

No sweat

Normal

Allegies *

Meat(s)

Vegetable(s)

Fruit(s)

Non

Weight *

Over weight

Below normal

Normal

I have completed this form and give the correct information

Thanks for submitting! Please complete Medical History and Symptoms (Questions form 2)

Medical History and Symptoms (Questions form 2)

Date of birth

Gender *

Male

Female

Dietary restrictions,if any of bowel movements per day.Please indicate if you regularly experience either *

Constipation

Diarrhea

IBS

Bloating

Hemorrhoids

Normal

Menstrual Cycle

Pre menopause

Pregnant

Post menopause

Cramps

Infertility

Irregular period

Missing period

No.I'm a male (The male patient selects this button)

Normal

Blood presure *

High

Low

Normal

Body pain *

Neck

Shoulder

Lower back

Joints

Headache

Numbness

Tingling

Non

Blood sugar *

High

Low

Normal

Diagnosis by Western medicine

In addition to the symptoms answered above,please write down other symptoms that you notice here

I have completed this form and give the correct information

Thanks for submitting! I will contact you later