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Urban acupuncture

Qi Flow Acupuncture ● 595 Blossom Road, Suite 315 ● Rochester NY 14610 ● 585-645-2151 / 585-205-3211
Confidential Health Information
Name_________________________________________________Date_____________Age_____Sex____ Address_______________________________________________________________________________ City_____________________________________________________State______________Zip_________ Telephone ______________________________E Mail Address__________________________________ Date of Birth___________________Occupation_______________________________________________ General Health Information

What are your major facial concerns? _______________________________________________________
______________________________________________________________________________________
What types of facial treatments have you received?____________________________________________
Within the last year, have you been under a dermatologist or other physician’s care? __________________
Within the last 9 months, have you undergone any surgery? _____________________________________
Do you smoke? _________How many alcoholic beverages do you consume weekly? ________________
How many glasses of water do you drink per day?______________________________________________
Do you exercise regularly? ________________Do you follow a restricted diet? _____________________
Do you wear contact lenses? ________________
Do you have metal implants? (head, face, neck) _______________________________________________


Rate your stress level on a scale of 1 to 4 (1 = low stress, 4 = high stress). 1 2 3 4
Qi Flow Acupuncture ● 595 Blossom Road, Suite 315 ● Rochester NY 14610 ● 585-645-2151 / 585-205-3211
Skin Health Information
Do you have any special skin problems pertaining to your face or body?____________________________ What skin care products do you use?________________________________________________________ ______________________________________________________________________________________ Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments?_________________ If yes, within the last month?__________________________ Do you use Accutane, Retin A, Renova, Adapalene, or any other RX skin care products?_______________ Are you currently using products that contain the following ingredients?____________________________ Glycolic acid Lactic acid Exfoliators Hydroxy acid(s) Vitamin A derivative (i.e. Retinol) Do you ever experience these conditions on your skin? Flakiness Tightness Obvious Dryness What SPF sunscreen do you use on your face?_________________________________________________ How much sun exposure to you get per week?_________________________________________________ Do you sunbathe or use tanning beds?_____________ Do you have sinus problems?__________________ Do you burn easily in moderate sunlight?_____________________________________________________ Do you drink more than 4 caffeinated beverages daily? (coffee, tea, soft drinks)______________________ Do you ever experience a burning, itching sensation on your skin? ________________________________ Have you ever had a reaction to any of the following? Cosmetics Medicine Iodine Food Pollen Hydroxy acid Animal Fragrance Sunscreens Other_______________________________________ Do you have any of the following?  Normal  Dry  Combination  Oily  Sensitive Skin conditions:  Acne  Eczema  Skin Allergies  Skin Cancer  Skin Rashes Female Clients Only
Are you taking oral contraception? _______________Are you lactating?___________________________ Are you pregnant or trying to become pregnant? ______________________________________________ Are you currently having or due for your menstrual period? ______________________________________ Signature __________________________________________Date_________________
Qi Flow Acupuncture ● 595 Blossom Road, Suite 315 ● Rochester NY 14610 ● 585-645-2151 / 585-205-3211
Contraindications to Facial Rejuvenation Treatment
If you have any of the following conditions, you should not receive facial rejuvenation treatments. Please ask your practitioner if you have any questions.  Cold or flu  Easy bruising or bleeding

 Pacemaker (microcurrent facial rejuvenation only)
 Seizures
 Uncontrolled high blood pressure
 Extreme rosacea or broken blood vessels on the face
 Irritated or bruised areas, warts, herpes, impetigo outbreaks on the face

 Implants
 Migraines
(Please resolve migraine headaches with acupuncture treatments or other means. Wait 3
months from the last migraine before receiving facial rejuvenation treatments.)
Are you pregnant?
(If yes, please wait until after your pregnancy to receive facial rejuvenation treatments.)
 Laser resurfacing
(Please wait 3 weeks before receiving facial rejuvenation treatments.)
 Botox
(Please wait 3-6 months before receiving facial rejuvenation treatments.)
 Microdermabrasion
(Please wait 2 weeks before receiving facial rejuvenation treatments.)

 Surgical facelift
(Please wait 3-6 months before receiving facial rejuvenation treatments.)

Qi Flow Acupuncture ● 595 Blossom Road, Suite 315 ● Rochester NY 14610 ● 585-645-2151 / 585-205-3211
Microcurrent Facial Rejuvenation Consent Form
I, ______________________________________________________________________ consent to receive microcurrent facial treatments, knowing that there are no guaranteed results. I acknowledge that I have been advised that using electrotherapeutic and cosmetic procedure could result in temporary redness or other skin symptoms. I completely understand and accept the above and agree to undergo these treatments. I have stated all medical conditions that I am aware of and will update the practitioner of any changes in my health status. ________________________________________________________________________ Patient Signature Date ________________________________________________________________________ Practitioner Signature Date

Source: http://www.qiflowacupuncture.com/wp-content/uploads/2011/10/Facial-Intake-Forms2.pdf

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