Consultation form

First name

Last name

Email

Mobile phone

Date of birth

Preferred name and pronouns

Occupation

How did you hear about us?

Is there anything that would make your visit easier?

GP name and surgery

Emergency contact: name and relationship

Emergency contact: phone number

If under 18: parent or guardian full name

If under 18: parent or guardian phone and email

Are you pregnant, could you be pregnant, or are you trying to conceive or having fertility treatment?

Do you take blood thinners or have a bleeding or clotting disorder?

Do you have a pacemaker, ICD or other implanted electrical device?

Have you had lymph nodes removed, or do you have lymphoedema?

Do any of these safety concerns apply to you?

Details of anything above

Have you had acupuncture before?

What is the main reason you are seeking acupuncture?

How long have you had this?

Is it getting better, staying the same or getting worse?

What makes it better or worse?

What other help have you had or are you having for this?

What would you most like to change or achieve from treatment?

Details of anything ticked

Current medications and supplements

Surgeries, injuries, accidents or trauma, with approximate year

Allergies

Cycle length, date of last period and contraception, if relevant

How many hours do you usually sleep?

How would you describe your diet and how much water you drink?

Caffeine, alcohol, smoking or vaping: roughly how much?

How often do you exercise, and what do you do to relax?

Is there anything else you would like us to know, or would find hard to say face to face?

I have answered the health questions honestly and to the best of my knowledge, will tell my practitioner if anything changes, and have read and understand the benefits and risks of acupuncture.

I consent to acupuncture treatment by my named practitioner at Health Tree Acupuncture. I understand I can stop or withdraw consent at any time.

I consent to my health information being stored securely as treatment notes and used for my care, as described in the Privacy Policy.

Health Tree Acupuncture may contact my GP if my practitioner considers it important for my care.

I am happy to receive appointment reminders and follow-up advice by email or text.

Typed signature: full name

If under 18: parent or guardian typed signature

The Canvas, 27 Old Ford Road, London E2 9PJ