DR. CHUN-KAI WANG, D.TCM 
15532 92A Ave, Surrey, BC, V3R 9B1 
604 832 3568 
------------- 
PRELIMINARY 1st-TIME PATIENT INTAKE FORM 

The confidentiality of this form will be honoured. No third party will have access without your authorization 

---------------- 

Name: 

Address: 

Phone(cell/primary): 

Email: 

Profession: 

Weight: 

Height: 

Date of Birth: 

Male/Female 

If Female, are you currently pregnant: Y/N 

If Yes, please state time since pregnancy:____ 
 
Are you currently breast feeding: Y/N 

First consult date: 

Chief Complaint: 
 
Current BP:  

History of: 

Stroke: Y/N if Yes, occurrence:
 
Heart Attack: Y/N if Yes, occurrence:
 
Epilepsy/Seizure: Y/N if Yes, occurrence: 
 
Allergies(rashes, etc): 

Heart Disease: Y/N Pacemaker: Y/N Diabetes: Y/N type:1/2 Hepatitis: A/B/C/D/E HIV/AIDS: Y/N 

Respiratory(COPD, asthma etc): Y/N if Yes, explain: 

Blood disorders(hemophilia, low platelet etc): Y/N if Yes, explain: 

Other:___ 

Any surgeries in past 5 yrs: Y/N If YES,explain___ 
 
Medical findings in past 5 yrs: 

Existing/Prior drug usage: Y/N used for:  

Existing/Prior supplement(including Chinese herbs) usage: Y/N 

Any unpleasant drug/herb interactions or experiences: Y/N

How is your:
Bowel movements? daily? how many times:
daytime urination:
nigh time urination:
digestion:
sleep:
menstruation: on time? how many days?
issues with sense organs:
head issues:
chest issues:
abnormal sweating?
------
 

PATIENT CONSENT TO TREATMENT 

 

This Consent to Treatment Agreement outlines the two main modalities used by the Doctor, acupuncture and Chinese herbal medicine. Herbal treatment includes the use of raw herbs and/or GMP herbal extracts. Herbal treatment is mostly a safe and stable form of therapy, but may elicit possible responses in certain patients with unique sensitivity, which may or may not occur. These include but are not limited to sweating, diarrhea, allergy-like rashes, etc. Patients should communicate with the Doctor if such events arise so appropriate actions are taken. Patients concurrently taking medications should space away taking of herbs from medications by 1-2 hours to avoid any possible side-effects. 

The Doctor is not authorized to make official Western Medical diagnoses of any disease, and will, in his best abilities, tell the patient to refer to the family physician if circumstances require. However, the Doctor will not be held responsible for any new diagnoses after herbal and acupuncture treatment, as it is impossible to say if this was a result of the Doctor's treatment, the natural progression of disease for which TCM was not able to control, or a preexisting disease unbeknownst to the patient prior to the time of TCM consultation. Therefore it is the patient's right to choose the treatment method he/she desires and also his/her responsibility to bear the consequences, whether positive or negative, of such treatment(s).  

I understand there are no refunds for the services and herbs given under this consent. This consent shall cover my current and any future treatments indefinitely. 

At any time this form may be given additions, be it new consents, clauses, terms, etc., which may have the power to override certain or all parts of this agreement provided the patient's new signature is given in the new addition(s). 

By writing the date and giving my signature below, I proclaim I have read the above, asked all relevant questions and understood the terms.  

DATE: 

 

PATIENT NAME(PRINT): 

 

PATIENT SIGNATURE: 

 

PATIENT GUARDIAN/REPRESENTATIVE SIGNATURE(IF UNDER 19 YR OLD and/or PATIENT UNABLE TO PERSONALLY PROVIDE CONSENT): 

 

Legal Relationship to Patient: 

 

PATIENT GUARDIAN/REPRESENTATIVE NAME(Print):_____________ 

 

CONTACT TEL: