Medical questionnaire
No.
Nationality

Mail・Femail

month,day,202

Name

Birth: month,day,202 ,years oldAddress

Introducer or what did you see

Phone

Email

Chief complaint: name:position:, type:, severity:
what might be cause:, how long (from m,year
expression factor:, aggravating factor:, mitigating factor:
hospital visit history / exam results:
Concomitant symptoms:)

Medical history
Previous major illness or surgery (,y/o)(,y/o)Current/previous illnesses（diabetes, hypertension, heart disease, hepatitis,）
Allergic symptoms (hay fever, atopy, food, metals, asthma,)
A major illness that your parents (), Famili structure ()Are you new to acu & moxa? (First time, past use, occasional use, frequent use)
Basic life Please enter number or circle if applicable
Sleep: time (nightto morning), satisfied with sleep time, sleep soundly,sleep normally, sleep lightly, can't sleep at all, can't fall asleep right away, wake up in the
middle of the night, trouble waking up at morning, often dream, don't feel like slept
Meals: number (times/day), amount (full, exactly, 80% full, 50% full)appetite (great/normal/no), snacking (daily/sometimes/never)favorite seasoning (sour, bitter, sweet, spicy, salty)
Bowel (daily, once1-2 days, constipated), (hard, normal, loose stools, diarrhea)
Urine (times/day), at night(times), volume(high/nor./low), color (yellow/trans.)
Symptoms of concern Please circle the symptoms if applicableirritability, eyestrain, need to finish, irregular menstruation, amenorrhea, cramps, stress,dizziness even when lying down, rheumatismprofuse sweating, palpitations, short breath, chest pain, excitability, dysgeusia, hot hands
stomach discomfort, belching, nausea, vomiting, abdominal pain, thinking a lot, worrying
coughing, runny or stuffy nose, skin abnormalities, stiff shoulders, many worries, sadness
tinnitus, hearing loss, fearfulness, startle easily, sluggishness, lightheadedness, hot soles
sensitivity to cold/heat, thirst, coldness, hot flashes, swelling, anemia, menstrual cramps
Occupation (）: administrator, clerical work, customer service, physical labor,housewife, student, unemployed, others ()height ( cm), weight (kg), body temperature (°C), blood pressure (blood tests (hepatitis or), drugs/supplements (liquor (kinds:cc/day), cigarettes (/day), sports (/mmHg)))©2023.4.1 Otsuka Clinic for AcupunctureConsent for treatment
In order to receive acupuncture and moxibustion treatments and beauty acupuncture
treatments, please fully understand the following explanations, and if you wish toreceive treatment, please sign this consent form.
・ Type of treatment
This treatment is composed of "acupuncture” and “moxibustion". "Acupuncture" refers tocontact or puncture of a specific part of the body surface with an acupuncture needle.
"Moxibustion" refers that moxa is burned or alternative substances are used to give thermal
stimulation to certain parts of the body surface.
・ Effect of treatment
The effect of acupuncture and moxibustion is divided into "immediate effect" and "posteffect", which are the cases where the effect appears immediately after the treatment, andthe cases where the effect appears after a certain period of time. In addition, there areindividual differences in how the effects appear and how long they last. Chronic symptoms
may take a relatively long time to show the effect of the treatment.
・During treatment
Acupuncture is a small stimulation on the body surface, but it can cause big changes in thebody. Please do not hesitate to tell us if you feel sick during the treatment or if you feel thatyour posture is painful.
・After treatment
Symptoms such as fatigue, dizziness, fever, pain, itching, and redness may rarely occur aftertreatment. Many of these symptoms are considered to be temporary due to improved bloodflow due to the treatment. If symptoms persist or worsen, please contact us.
・Feature of acupuncture
Since acupuncture needles are inserted into tissues such as the skin, capillaries, and muscles,
there is the possibility of subcutaneous bleeding or very slight bleeding. Bleeding or
subcutaneous bleeding due to acupuncture is due to the body's normal response and not due
to an error in the treatment. In rare cases, bruising may occur due to subcutaneous bleeding,but it disappears naturally in one to several weeks depending on individual differences.
・Feature of moxibustion
Moxibustion techniques, such as heating with the small moxa a half size of the grain of rice,extinguishing or removing moxa before it burns out, or pedestal moxa where moxibustion
does not come into direct contact with the skin, are used. Moxibustion technic is applied
while adjusting the amount of heat according to how you feel the heat, but in rare cases
blisters, burns, and scars may remain depending on conditions such as those with weak skinor the skin is damp due to sweat.
・About information
Information may be used for papers, academic conferences, etc, however, by which
individuals are not identified. Messages from clinic may send to you.
If you wish to receive acupuncture and moxibustion treatment, please understand theabove and give your consent to receive the treatment.

I have received a sufficient explanation regarding the above matter and haveunderstood it, so I consented to receive the treatment.
Name of consenter©2023.4.1 Otsuka Clinic for Acupuncture