Patient Record Guidance for Acupuncture Society Members
Initial Consultation and Treatment Records with Consent Form (to be signed by patients prior to treatment)
Patient or practitioner can fill in this section:
Date:
Patients Name:
Address:
Phone Number:
Email:
Medication:
Medical History:
Medical Diagnosis:
Chief Complaint:
Other Complaints:
Please ensure you let your practitioner know prior to treatment if any of the following apply:
(Patient to tick appropriate one/ones if not already included in the medicial history section):
- A recent operation
- An untreated medical condition
- Severe Bone or joint disorders (Rheumatoid/Osteo arthritis, osteoporosis)
- Cardiovascular disorders (high blood pressure, heart / circulatory desease, thrombosis)
- Diabetes
- Endocrine disorders
- Epilepsy
- Drug addiction or recent use of cocktails of recreational and prescribed drugs and or exessive alcohol consumption
- Medication
- Pregnancy (or post natal)
- Severe skin disorders
- Severe mental illness
- Spinal injuries
- Prone to fainting
- If you suffer from infectious deseases like Hepatitis B or HIV
Practitioners TCM and/or Medical Assessment of the patient’s condition: (Practitioner to fill in):
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Please encircle below recommended treatments:
Acupuncture, Chinese Herbal Medicine, Tuina, Shiazu, Acupressure, Oriental Massage, Moxibustion, Cupping, Gua Sha, Auricular Acupuncture, Cosmetic Acupuncture, Tens, Infrared Lamp, Electro Acupoint Stimulation, Lazer Acupoint Stimulation, Magnetic therapy, Korean Acupuncture, Korean Reflexology.
State any additional therapies used:______________________________________________________
Contra indications for Acupuncture treatment
Please ask your patient to read and tick either yes or no to the following:
(If they encircle yes or you suspect this is the case and they haven’t been clear about it you must decline treatment)
Are you diabetic and haven't taken your medication? Have you not eaten today? Are you intoxicated on drugs; medication or a cocktail of intoxicant’s either today or last night? Are you pregnant? Do you have allergies reactions or frequent feinting? Do you suffer haemorragic desease and are prone to bleeding?
Patient please encircle Yes or No
and tick which question/questions above apply
Treatment Precautions:
Contra indications and guidance for safe cupping
Heavy cupping to be avoided
Patients must be clear as to what to expect
No abdominal or lumber sacral cupping during pregnancy
No heavy facial cupping
Avoid cupping patients who are prone to bleed easily or have allergic skin conditions
Where fire cups are used extra care must be taken (we recommend cold cupping with suction pump as there is more control and less risk of burning accidents)
Cups must not be left on for too long as heavy bruising is not usually appreciated in the UK
Contra indications and guidance for safe moxibustion
Skin to be protected at all times and hot ash droppage must be prevented, serious attention must be given to the prevention of burns and moxa must not be applied on oils or Vaseline and this can result in serious burning
Contra indications and guidance for safe Acupressure, Oriental Massage Tuina and Shiatzu
Caution during pregnancy, with allergic skin conditions, avoidance of treating or using manipulations or strong pressure on conditions with serious skeletal, structural or medical conditions not fully understood
Patient consent to treatment
(Patients to sign here to indicate consent)
I _______________ (Patient Name) agree to receive the following treatments:
_______________________________________________________________(state treatments here),
which have been fully explained to me, including what to expect during and following treatment and any possible side effects or reactions
Patient to sign here and date:
_______________________________________
At the begining of each follow up treatment the Patient must be asked (and practitioners must note and record)
Patients Name
Treatment date
(Patients response to these 2 questions)
Did you have any good or adverse experience to treatments? _________________________________
What level of improvement or deterioration? (on 1 to 10 bases) ________________________________
(Practitioner to explain the following to patient and note):
In your professional opinion if the condition is worse - what is the explanation, and was this a temporary or long term effect?
_________________________________________________________________
_________________________________________________________________
Practitioner to record all treatments administered each time including treatment protocols and variations on assessment conclusions
Practitioner must appropriately refer patient when they do not fully understand the progress of treatment or the patient’s condition
Practitioner to tick the area where the chief complaint is located below and indicate a relevant description of symptoms
