Acupuncture Ottawa Form Orleans Acupuncture & Chinese Medicine Form - Orleans This form will take approximately 10 minutes to complete. If you would like to save your form and continue at another time, you may do so via the link at the bottom of each page. An email will then be sent to you with a link to complete the form when you wish to continue. This form is secure and all information is confidential. Thank you. Step 1 of 4 - PERSONAL INFORMATION 0% Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Home PhoneCell PhoneWork PhoneEmail* I consent to receiving email communication from Oaktree*Emails we will send you will include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email.YesNoGenderFemaleMaleWeight (lbs)HeightBirthday* Age*WorkplaceOccupationWho referred you to Oaktree?Marital StatusSingleCommon lawMarriedDivorcedSeparatedWidowedOtherDo you have extended health care benefits that contribute to acupuncture care?YesNoUnsureAmount of acupuncture benefits per year: Save and Continue Later ACUPUNCTURE HISTORYHave you ever been to an acupuncturist before?YesNoName of AcupuncturistCity City Date of last visit (approximate year/month)Duration & Frequency of CareFor how long did you see your acupuncturist and how many times per week? Save and Continue Later MAJOR COMPLAINTS & MEDICAL HISTORYPlease list your major complaints(s) in order of significance to you.Please list major complaint(s). Add an additional line for each additional complaint. SUPPLEMENTSDo you take any supplements?YesNoWhich supplements do you take?Check any/all that apply. Omega3 B vitamins Probiotics Vitamin D Multivitamin Iron Other What other supplements do you take?Please list any other supplements you take. Add an extra line for each additional supplement. MEDICATIONSDo you currently take any medications?YesNoWhat other medications do you take?Please list any medications you take. Add an extra line for each additional medication.Name of medicationUsed for what condition SURGERIESHave you ever had surgery? Yes No What surgeries have you had performed?Please list any surgeries you have had, including the date and for what condition. Add an extra line for each individual surgery.Year PerformedFor what condition FAMILY HEALTH HISTORYWhat significant health concerns have your family members experienced?Please list any health concerns your family members have experienced. Add extra lines for additional concerns. Save and Continue Later OTHER HEALTH PROBLEMS, CONCERNS OR ADDITIONAL INFORMATIONPlease enter any other details that may assist us in understanding your lifestyle and health status:CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.