New Patient Long Form

Please note, this is a long form. You may need half an hour to complete it.

Important note for iPhone/iPad users: The form may not function correctly if your operating system is out of date. To avoid your information being lost, please ensure you have the latest version of software available.

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For your safety and protection and for our information, please answer the following questions relevant to you:
Main Complaints
(0 = no discomfort,10 = extreme discomfort):
(0 = no discomfort,10 = extreme discomfort):
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How was it confirmed?
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Rate on a scale of 1-10 (1 being lowest, 10 being highest):
Rate on a scale of 1-10 (1 being lowest, 10 being highest):
Rate on a scale of 1-10 (1 being lowest, 10 being highest):
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Diet
39. Based on your food intake for one day, what do you typically eat?
43. How many cups do you drink per day of the following beverages?
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Bodily Functions - Signs/Symptoms
PLEASE NOTE: In Traditional Chinese Medicine, all illness stems from an imbalance in one of the five main organs, heart, liver, lungs, kidney and spleen. These questions are grouped into symptoms of illness for each organ to determine which is out of balance. Complete these questions as thoroughly as possible, please be honest with yourself. Some of the questions that follow may seem unrelated to your condition, BUT they may play a major role in diagnosis and treatment. By filling this in we will be able to give you an idea of how your conditions relate to the organs according to Chinese Medicine. All information is strictly confidential.
55. Do you experience musculoskeletal pain? (e.g. joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) If yes:
Men's Health- please skip if this section does not apply to you
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Women's Health - please skip if this section does not apply to you
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Emotions
Health & Wellness Levels

75. Many factors affect our lives in various ways. These factors weave a web of health and wellbeing. Please rate your level of satisfaction in each of the areas (1 = Not happy at all, 10 = Very happy):

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In accordance with the Privacy Act all information recorded in your health records will be kept confidential. Under the Privacy Act you have the right of access to and correction of your personal information held by this practice. No information will be given to a third party without your permission.
Consent to Treatment
I AGREE to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so.
I UNDERSTAND that I must pay for private treatments, cancellation fees and the costs of materials (splints, strappings etc.) and herbs, and any treatments declined by ACC/work insurance.
I UNDERSTAND that any unpaid bills may be referred to a debt collector and I agree that I will be responsible for the debt collection fees, and the administration fee of $50 incurred for accounts sent to debt collection.
I UNDERSTAND that I have the right to decline part or all of the treatment offered to me at any time and I can ask for a second opinion or change my treatment provider in accordance with Section 7 of the Code of Health & Disability Services Consumer Rights 1996.
I UNDERSTAND that I can ask the staff for an explanation of treatment I am receiving at any time and that in accordance with Section 10 of the Code of Health and Disability Services Consumer Rights 1996, I have the right of complaint.
I UNDERSTAND that there is a 24-hour cancellation and rescheduling policy that will result in a fee of the full price of treatment should I not give sufficient notice. 

Telehealth Consultation - Patient Consent, Disclaimer and Release (The following only applies to patients who are having telehealth consultations).

I hereby attest that I have requested and authorized Szenan Phua (The Practitioner) to arrange an online consultation for me with him. Via this consultation The Practitioner will assess my condition and offer advice on use of self acupressure to treat my condition at home and/or prescribe herbs. I will be responsible for finding a place to fill the herbal prescription. The Practitioner will base this assessment solely on the information provided by me to him via a patient form and the consultation itself.
I understand and agree that:
· The Practitioner’s telehealth consultation is solely based on the information provided by me and, in the absence of a physical evaluation, The Practitioner may not be aware of certain facts that may limit or affect his assessment or diagnosis of my condition and recommended treatment.
· The telehealth consultation is very different from a regular face-to-face examination and that The Practitioner is limited by the information provided by me. Accordingly, the diagnosis I will receive is limited and provisional.
· A telehealth consultation is not intended to replace a full face-to-face evaluation.
· I will not have direct contact with The Practitioner unless I decide to travel to Hamilton, New Zealand for an evaluation afterwards.
· The Practitioner is only rendering a telehealth consultation and does not assume any responsibility for my continued medical care or treatment.
· I am responsible for all the expenses related to my telehealth consultation request including, but not limited to, consultation fees, phone charges if necessary.
· My medical information will be handled with strict confidentiality, privacy and security; however, I understand there are risks associated with any electronic transfer process from one location to another.
· I solely assume the risk of the limitations set forth herein, and I further understand that no warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.
Disclaimer and Release
I hereby completely and irrevocably release Ji De Tang Ltd and Szenan Phua and Phua Ltd and their respective medical staff members, physicians and other health care professionals, insurance providers, administrators, officers, employees and directors (collectively, the “Ji De Tang Ltd Released Parties”) of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the telehealth consultation, conclusions or recommendations provided by Ji De Tang Ltd or The Practitioner. Furthermore, I agree that the Ji De Tang Ltd Released Parties have no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission.
By accepting and agreeing to these terms, I acknowledge and agree to assume the risks of the limitations set forth herein.
As a condition to receiving the telehealth consultation service, I have read and acknowledge that I have given this consent of my own free will.
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