Patient Intake Form Notify Welcome to Bernadette Yu Wellness! Are you an EXISTING or NEW patient? Existing NewKnown medical diagnosis: (Please check if applies) AIDS / HIV Cancer Diabetes Haemophilia Heart Disease Hepatitis B Hepatitis C Seizures Tuberculosis Previous Fall / Accident Osteoporosis Iron deficiency Vitamin B12 deficiency Vitamin D deficiency Hypothyroid Hyperthyroid Cirrhosis Known communicable diseases Fibromyalgia Lupus Multiple Sclerosis I've other medical diagnosis I've no medical diagnosisPrimary Health ConcernsPurpose Of Visit: Acupuncture with Assessment Facial Acupuncture with Assessment Chinese Herbal Medicine with Assessment Bioenergetic Organ Health Evaluation Bioenergetic Food Compatibility Test Nutritional Consultation Healthy Pregnancy Preparation Session Cancer Recovery Planning SessionWhere did you hear about us?Please List Any Medication You Are TakingName of prescribed medicationSurgery HistoryCurrent health habits and symtoms:Your Lifestyle Alcohol use Tobacco use Marijuana use Other illegal drug use Exercise - not much Exercise > 2-3 x/week Take Vacation Yearly Take no Vacation at all Stressful job / lifestyle Occupational hazards Vegetarian Vegan Heavy meat eater Limited / no fish Limited / no shell fish Limited / no dairy Limited / no egg Limited / no gluten Limited / no other grains Limited / no red meat Limited / no poutry Limited / no nuts and seeds Limited / no legume and beans Limited / no starchy food Limited / no vegetables Limited / no fermented vegetables Frequent skipping meal Sleep late Inadequate sleep Drink less than 6 glasses of water daily Take no supplementGeneral Symptoms Poor appetite Heavy appetite Prefer cold drinks Prefer hot drinks Sudden weight gain Sudden weight loss Difficulty falling asleep Dream-disturbed sleep Awake easily Wake up tired Fatigue after meal Fatigue all day Lack of muscle strength Bodily heaviness Head heaviness Poor circulation Numbness of the hands Numbness of the feet Numbness of the face Numbness of the arm(s) Numbness of the leg(s) Feverish sensation Chill sensation Heat sensation Sour taste in the mouth Bitter taste in the mouth Sweet taste in the mouth Metal taste in the mouth Sweat - excess Sweat - not much Sweat while sleeping Cold Feet Hot Feet Cold hands Hot hands Vertigo Dizziness Muscle cramps Bleed easily bruise easilyHead, Eyes, Ears, Nose, Throat Wear glasses Eye strain Eye pain Eye redness Eye burning sensation Eye itchiness Eye tearing Eye seeing floaters Poor day vision Poor night vision Blurred vision easily Night blindness Glaucoma Cataracts Teeth problem Grinding teeth TMJ Pain Facial pain Gum problem Sore lips Sore tongue Dry mouth Drooling Tongue burning Mouth burning Excessive saliva Excess thirst Loss of taste Loss of smell Sinus problem Excessive phlegm Bitter taste upon waking Bitter taste all day Chronic sore throat Swollen glands Lumps in the throat Enlarged thyroid Frequent nose bleed Loud ringing in ear Low ringing in ear Poor hearing Ear ache Ear burning Frontal headache Whole head headache Headache on the left side Headache on the right side Occipital headache Migraines Head injury history Hay fever Food allergyRespiratory Difficulty Breathing if lying down Tight chest Shortness of breath Asthma wheezing More cough at night More cough during the day Wet cough Dry cough Coughing up blood Frequent colds Frequent Flu COPDCardiovascular High blood pressure Low blood pressure High blood sugar On blood thinner Chest pain History of heart attack Heartbeat fast Heartbeat slow Heartbeat irregular Palpitations Cholesterol problem On cholesterol drugGastrointestinal Nausea Vomiting Acid regurgitation Stomach pain Ulcer Frequent Hiccup Frequent burping Eats little and feels full Bloating Bad breath Abdominal pain Hiatus hernia Crohns Colitis Blood in stool Mucus in stool Grey color stool Black color stool Hard stool Pellet-like stool Strong odor stool Loose stool Diarrhea Frequent defecation Frequent constipation Intestinal pain Intestinal cramps Itchy anus Burning anus Rectal pain Haemorrhoid Anal fissures Frequent use of laxative Undigested food in stool fatty liverMusculoskeletal Neck pain Shoulder pain Upper back pain Lower back pain Joint pain stiffness Left rib pain Right rib pain Plantar foot pain Gout Arthritis Sporadic sharp pain Constant dull painSkin, Nail and Hair Rashes Hives itchy skin Dry skin Skin ulceration Eczema Psoriasis Acne Excess dandruff on the scalp Itchy scalp Diffuse hair loss Patchy hair loss Full-body hair loss Hair texture change Skin texture change Skin color change Fungal infection Thin nail Brittle nailNeuropsychological Tics Poor memory Depression Anxiety Anger Easily stressed Abuse survivor Suicidal tendency History of stroke Neuropathic pain Parkinson's disease Multiple Sclerosis Cerebral palsy Bipolar disorder Dementia ADD / ADHD Autism Anxiety disorder Panic disorder Anorexia nervosa Bulimia nervosa Obsessive-compulsive disorder Post-traumatic stress disorder Personality disorderGenito-urinary and reproductive Painful urination Frequent urination Urgent urination Blood in urine Unable to hold urine Incomplete sensation Bedwetting Frequent waking to urinate Bladder distention/pain Frequent urinary tract infection Bladder stone Kidney stone Enlarged prostate Prostatitis Nocturnal emission Premature ejaculation Impotence Decreased libido Excessive libido Pain during sex Genital herpes Genital warts Other sexual transmitted disease InfertilityGynaecology Menses began before age 12 Menses began after age 16 Cycle length less than 28 days Menstrual flow =< 2 days Red menstrual blood Dark red menstrual blood Bright red menstrual blood Presence of dark red clots Presence of bright red clots Painful periods Heavy periods Very light periods Irregular periods Missing periods Bleeds between periods Uncontrollable bleeding Excess discharge Fishy discharge Foul discharge Frequent vaginal infection Abdominal pain during period Back pain during period Headache during period Nausea and vomiting during period Dizziness during period Muscle tingling during periods Vaginal sores Vaginal dryness Vaginal itchiness Painful intercourse Breast lump Breast discharge Fibroid Endometriosis Ovarian cyst(s) Blocked tubes Had never been pregnant Abnormal Pap result Hot flashesPlease write down the "ONE THING" that matters to you the most and which can be achieved / improved by fixing your Primary Health Issue.Now, on a scale of 1 to 10 (10 being the highest), rate your commitment to improving/fixing your Primary Health Concern. Please select the number. 1 2 3 4 5 6 7 8 9 10Interested to know which supplements and foods can address your health issues? Tick here for practical advice during your appointment. Additional fees: $100 + tax (may be covered by insurance under "Holistic Nutrition"). Yes, I would like to receive supplement and diet advice. I understand a fee of $100 + tax will apply to this additional service.If interested in receiving a Chinese herbal medicine prescription during your acupuncture session, tick the box. A fee of $50 + tax applies, excluding the cost of the herbs. Orders can be placed separately at Cost + shipping and relevant taxes. Your visiting fee may be covered by your insurance health-care spending account. Yes, I would like to receive Chinese Herbal Medicine Prescription. I understand a fee of $50 + tax will apply to this additional service.Terms and ConditionsI acknowledge the effectiveness of Acupuncture, Chinese Herbal Medicine, dietary/nutritional therapy, and other TCM methods for preventing and treating various health issues and enhancing overall well-being. While beneficial for many conditions, I understand these treatments do not substitute any medical tests or therapies advised by my physicians. I will maintain my prescribed medications alongside any alternative treatments received at this clinic.I've shared my health details and medications with the TCM Practitioner/Acupuncturist/Registered Nutritionist and will keep them informed of any changes. The practitioner isn't liable for omissions in information. I recognize no guarantees are given, and the effectiveness of treatments can be influenced by medications and lifestyle. I take full responsibility for my treatment outcomes.I acknowledge that Acupuncture and related TCM practices are generally safe. Bruising from needle insertion is normal, while fainting is rare but can occur due to extreme nervousness, hunger, or fatigue. Needling sensitive points below the waist or near the breasts may be required, and verbal permission will be sought. Herbal medicines are usually safe and effective, although some may experience occasional side effects like abdominal upset, diarrhea, or sweating in response to treatment.Clinic Fees & PoliciesFees for initial appointments with an assessment, diagnosis and treatment are as follows:Acupuncture with cupping or TCM Tuina Massage: $135Guasha (Scraping) appointment: $135Facial Acupuncture: $155Nutritional Consultation: 150 + taxBioenergetic Organ Health Evaluation: $200 + taxFood Compatibility Test, Pregnancy Success Preparation Session, or Cancer Recovery Planning Session: $300 + tax eachChinese Herbal Medicine Consultation Only Visit: $100 + tax (initial appointment). Chinese herbs can be purchased at cost plus shipping. Herbal medicine refills incur a $10 administration fee plus cost of the herbal medicine, shipping and tax.Nutritional guidance request during your treatment, with personalized supplement and dietary recommendations provided via text or email: an additional $100 + tax, Please be punctual for all scheduled appointments. If you arrive late and cannot receive services due to time constraints, and your spot could be taken by another patient, a $100 fee will be added to your next visit, unless a medical emergency caused the delay.You consent to the practitioner(s) review, analyze and store your submitted information. The practitioner(s) can respond to your input or provide feedback, advise by either email, phone or text messages.First NameLast NameEmailPhone NumberEmergency Contact's First NameEmergency Contact's Last NameEmergency Contact's Phone NumberDate of Submission[fluentform id="8"] Sign HereSubmit Form
