Consent & Initial Intake

Please complete to understand potential risks and our cancellation terms and conditions.

Credit Card Details

Zhong Centre collects credit card details from all patients in line with our cancellation policy. Our cancellation policy is in place to ensure that all patients are afforded the care and attention they require and that if you do need to cancel your appointment, we have adequate time to book another client into your appointment schedule.

With that in mind, if you need to cancel your appointment, we ask that you provide at least forty-eight (48) hours notice, you will not be charged.

If you cancel your appointment within forty-eight (48) hours, we will charge the credit card we have on file for you 50% of the consultation fee. If you cancel within twenty-four (24) hours, we will charge the credit card we have on file for you 100% of the consultation fee.

By submitting this form, you consent to our cancellation policy and our keeping your credit card details on file. You may revoke this consent at any time by emailing Zhong Centre Note that we cannot provide you with an appointment without your consent to our cancellation policy.

Note that all fields are required.

(The CVV is the 3 digits on the back of Visa or MasterCard cards or the 4 digits on the front of an American Express)

Initial Consultation & Consent
This form begins to provide us with in-depth background information on your general health and well-being. The questions are mostly multiple choice, and will take around 10-15 minutes to finish. All information provided in this form is confidential, so please answer truthfully to enable the practitioner to have a deeper understanding of your health and ongoing health care concerns.

Contact phone number

Your Birthdate

How did you hear about Zhong Centre?
(If a friend, let us know their name)

Emergency Contact / Next of Kin

Contact phone number

Zhong Centre - Conditions & Informed Consent

As a client, we need you to be aware of and understand the Cancellation policy we have in place at Zhong Centre. Please be aware that if you No Show or Cancel within 24 hours of your booked appointment, the Full Fee (100%) of your booked service will apply. Re-scheduling outside this time frame is fine by contacting us on 0481 825 525. It is a clinic policy for us to securely and confidentially store credit card details for the purpose of confirming your initial booking.

We need you to be aware of and understand that in all forms of health care there may be some very slight risks as a result of Acupuncture and Chinese Medicine treatment. Not uncommon: feeling at the needle insertion site itchiness, minor bleeding, and dull achy feeling possibly lasting up to 2-3 days.
Occasionally – temporary exacerbation and/or aggravation of symptoms. Rare – Pneumothorax, nerve pain, punctured organs, hematoma, bruising and needle shock.

I am assured that any questions I may have about my personal care will be fully and honestly answered to the best of practitioner's ability and I am aware and agree with this policy.

Please type your name in the box below to give your consent and you are aware and agree with this policy.

GENERAL HEALTH QUESTIONS
What is the main problem you would like help with?

How long ago did this problem start?

Have you been given a diagnosis for this?

What type of treatments have you tried?

How many cigarettes do you smoke a day?

How many coffee/tea/drinks do you drink a day?

Are you taking any recreational drugs?

Do you have any known drug allergies or reactions?

Are you currently taking any medications or supplements?

Is there any other medical or health conditions that the practitioner needs to be aware of including blood borne diseases?

Medical Conditions: Check All That Apply
No Medical ConditionsGerman MeaslesMigrainesProlonged DizzinessChronic FatigueMRGlandular FeverPneumoniaThyroid Problems (Western medicine clinically diagnosed)TuberculosisAsthmaBronchitisOther Lung ConditionsGlasses / Contact lensesHeart AttackHeart MurmurRheumatic FeverOther Heart ConditionsHigh Blood PressureLow Blood PressureGastric / Duodenal UlcerHepatitisIntestinal BleedingBleeding TendencyHaemaphiliaBlood ClotsProblems with AnesthesiaDiabetes Type IDiabetes Type IIKidney InfectionsKidney StonesFrequent UTI's / Bladder InfectionsOther Kidney DisordersRheumatoid ArthritisOestoarthritisOther forms of ArthritisLupus ErthematosusParalysisNeurological DisordersThromboidosisVaricose VeinsBreast CancerUterine / Ovarian CancerProstate CancerBowel CancerLiver CancerSkin Cancer / MelanomasOther CancerLymphnodes removedBreast CystsBreast Lumps (benign)Any ImplantsBotoxCosmetic fillersCosmetic enhancement (tummy tuck, facelift, agumentation, eye lid etc)

What is your main occupation?

Do you have any children?

SHEN YIN / JING XU
Do you have any lower back weakness/soreness/pain or knee problems?

Do you have ringing in your ears?
Yes - high pitchYes - low pitchNo

Do you have any dizziness?
YesNo

Is your hair prematurely grey?
YesNo

Do you suffer vaginal dryness?
YesNo

Do you have dark circles under your eyes?
YesNo

Do you experience night sweats, clamminess, or overheat at night (when sleeping)?
NoYes - sweatsYes - clammyYes - hot

Are you prone to hot flushes?
YesNo

Do you experience fear in your life?
YesNo

Is your mid-cycle cervical mucus scanty or missing?
I don't have a periodYes - scantyYes - missingNo

SHEN YANG XU

Is your lower back weak or sore?
YesNo

Do you get lower back pain premenstrually?
YesNoMale

Are your hands and feet predominantly cold?
YesNo

Are you typically colder than those around you?
YesNo

Is your libido low?
YesNo

Do you have to get up to go to the bathroom at night when you are sleeping?
YesNo

Do you urinate frequently? Is your urine diluted?
Yes - frequentYes - dilutedNo

Do you have early morning loose stools?
YesNo

Does your menstrual blood tend to be dull in colour?
YesNoMale

Do you feel menstrual cramping is improved with heat packs?
YesNoMale

Are your feet cold (especially at night)?
YesNo

Is your lower abdomen (below your belly button) cooler to touch than the rest of your trunk?
YesNo

Is your energy low after a meal?
YesNo

PI QI XU

Are you often fatigued?
YesNo

Is your energy low after a meal?
YesNo

Do you feel bloated after eating?
YesNo

Are you more prone to craving sweets or breads?
YesNo

Do you have abdominal pain or digestive problems?
YesNo

Are your hands and feet cold?
YesNo

Is your nose cold?
YesNo

Are you prone to heaviness / fogginess in your head (especially when waking up in the morning?)
YesNo

Do you bruise easily?
YesNo

Do you have poor circulation?
YesNo

Are you prone to worrying?
YesNo

Have you been diagnosed with low blood pressure?
YesNo

Are you prone to feeling heavy or sluggish?
YesNo

Are you prone to feeling foggy in your thinking?
YesNo

Are you lacking strength in your arms and legs?
YesNo

Do you find it difficult to exercise?
YesNo

XUE XU

Are your periods light in flow? (Changing less than 3x a day)
YesNoMale

Are your periods sometimes late?
YesNoMale

Do you have dry or flaky skin?
YesNo

Are your lips prone to chaffing?
YesNo

Are your nails brittle?
YesNo

Are you losing a lot of hair from your head when you wash/brush it?
YesNo

If your hair dry or brittle?
YesNo

Is your night vision poor?
YesNo

Do you get shortness of breath?
YesNo

Do you experience palpitations, heart flutterings or sternum/chest tightness?
YesNo

Do you get dizziness or light-headedness around your period?
YesNoMale

XUE YU (STASIS)

Is your menstrual flow ever brown or black in colour?
YesNoMale

Is the blood thick, dark or purplish in colour?
YesNoMale

Does your menstrual flow contain clots?
YesNoMale

Do you experience pain during ovulation?
YesNoMale

Do you experience stabbing or searing/piercing pain during your period?
YesNoMale

Have you been diagnosed with endometriosis or uterine fibroids?
YesNoMale

Do you have fibrous breasts?
YesNo

Do you experience periodic numbness of your hands and/or feet?
YesNo

Do you have chronic haemorrhoids?
YesNo

Is your lower abdomen tender to touch?
YesNo

Is your lower abdomen lumpy with hard areas?
YesNo

Have you been diagnosed with any vascular abnormality?
YesNo

Do you have any dark spots in your vision?
YesNo

GAN QI YU

Are you prone to emotional depression?
YesNo

Are you prone to rage or anger?
YesNo

Do you suffer PMS? Are you easily irritable premenstrually?
YesNoMale

Do you feel bloated premenstrually?
YesNoMale

Are your breasts more sensitive or tender during ovulation?
YesNoMale

Are your breasts more sensitive or tender premenstrually?
YesNo

Have you been diagnosed with high prolactin levels?
YesNoMale

Do you experience any nipple discharge?
YesNo

Do you have difficulty falling asleep at night?
YesNo

Do you experience heartburn?
YesNo

Do you wake up with a bitter or metallic taste in your mouth?
YesNo

Do you experience pain during menstruation?
YesNoMale

Do you experience menstrual cramps in your vagina or genital region?
YesNoMale

XIN XU

Do you wake early in the morning and have difficulty getting back to sleep?
YesNo

Do you experience an awareness of your heart beating especially when you are stressed or nervous?
YesNoOccasionally

Do you experience vivid or excessive dreaming and/or nightmares?
YesNoOccasionally

Are you experiencing diminished vitality or mood?
YesNoOccasionally

Are you currently feeling restless and/or agitated?
YesNoOccasionally

Do you find yourself sweating more so than usual, especially on the chest?
YesNoOccasionally

SHI HEAT
Is your pulse rate rapid?
YesNoOccasionally

Is your mouth and throat usually dry?
YesNoOccasionally

Are you thirsty for cold drinks most of the time?
YesNoOccasionally

Do you often feel warmer than those around you?
YesNo

Do you wake up sweating or experiencing hot flushes?
YesNo

Do you break out in red acne?
NoOccasionallyYes - ForeheadYes - JawlineYes - Upper BackYes - T-SectionYes - CheeksYes - Shoulders

Do you get premenstrual acne?
NoOccasionallyYes - ForeheadYes - JawlineYes - Upper BackYes - T-SectionYes - CheeksYes - Shoulders

Do you have a short menstrual cycle (less than 27 days between periods)?
YesNoMale

Do you have (or regularly experience) any genital irritation or rashes?
YesNoOccasionally

DAMPNESS & DAMPHEAT
Do you feel sluggish and tired after a meal?
YesNo

Do you have fibrous breasts or cysts?
YesNo

Do you experience cystic or pustular acne?
NoOccasionallyYes - ForeheadYes - JawlineYes - Upper BackYes - T-SectionYes - CheeksYes - Shoulders

Do you have urgent, bright or foul smelling stools?
YesNoOccasionally

Does your menstrual blood contain tissue, fibrous bits or mucous?
YesNoOccasionallyMale

Do you joints ache, especially with movement?
YesNo

Are you overweight?
YesNo

Are you prone to yeast infections or genital area itchiness?
YesNo

Do you have damp, sticky and usually unformed stools?
YesNoOccasionally

Do you experience foul-smelling yellow or green tinged discharge (from penis or vagina)?
YesNoOccasionally

Do you have a slimy sensation on your tongue?
YesNo

Do you have any dietary preferences: Check All That Apply
VegetarianVeganPescatarianGluten-freeDairy-freeFructose-freeOther

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