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The Maternity Acupuncture Clinic

Anna-Lena Tews

Please fill in the following details PRIOR to your first appointment to assist with your best treatment plan.
Thank you for your time!

I collect this information to provide safe maternity acuneedling care. Your information will be stored securely and only accessed by Anna-Lena Tews, Midwife. You may request a copy or correction of your records at any time, in accordance with the NZ Privacy Act 2020 and Health Information Privacy Code 2020.

Providing your information is voluntary. You do not have to provide all details, but some information is needed to ensure your safety during the treatment.

Personal Details

Full Name*

First

Phone Number*

Email Address*

Date of Birth*

DD slash MM slash YYYY

Nationality*

Street*

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House Number*

Postcode*

Town / City*

Emergency Contact Name*

Emergency Contact Phone Number*

Name of Your Midwife*

Phone of Your Midwife*

Reason for Attending the Clinic Please select the reason(s) for attending the clinic:*

Reason for Attending the Clinic **

General Pregnancy Support

Morning Sickness

Miscarriage

Anaemia

Heartburn

Constipation

Musculoskeletal conditions

Fatigue and exhaustion

Urinary Tract Infection

Thrush and abnormal vaginal discharge

Pelvic Pain / Hip Pain

Back Pain

Sleep Issues

High Blood Pressure (pregnancy induced)

Itching

Oedema

Anxiety or Stress

Depression

Labour Preparation

Optimal foetal positioning

Breech Presentation

Induction of labour

Postpartum Recovery

Increase of milk supply

Mastitis

How many gestational weeks and days are you today? *

Weeks*

Days*

Medical History Do you have any of the following medical conditions? (Check all that apply)

Medical History

Diabetes

High Blood Pressure

Thyroid Issues

Autoimmune Disorder

History of Miscarriage

Asthma or Breathing Issues

Heart Condition

Epilepsy or Seizure Disorder

Previous Surgery (Please specify):

Any Other Chronic Illness (Please specify):

Have you ever been diagnosed with:

Endometriosis

PCOS (Polycystic Ovarian Syndrome)

Fibroids

Have you ever been diagnosed with:

Other reproductive health conditions (Please specify)

Previous Births Please list details of your previous pregnancies and births:

Pregnancy

Birth Type

Vaginal

Caesarean

Assisted Birth (Vacuum, Forceps)

Complications

Yes

If yes, please describe

Baby’s Health

Healthy

Premature

NICU Stay

Years

+ ADD BIRTH

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This is my first baby

Current Pregnancy Risks Do you have any of the following risks in your current pregnancy? (Check all that apply)

Pregnancy Risks

High Blood Pressure

Gestational Diabetes

Pre-eclampsia

Multiple Pregnancy (Twins/Triplets)

Miscarriage History

Premature Labour History

Placenta Previa

Bleeding or Spotting

Other Risk Factors (Please specify):

Infectious Diseases Please indicate if you have been diagnosed with any of the following infectious diseases or conditions during this pregnancy:

Infectious Diseases

Influenza

COVID-19

Toxoplasmosis

Listeria

Hepatitis B or C

HIV

Chickenpox

Genital Herpes

Other (Please specify):

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Smoking*

Do you smoke or vape?

Yes

Treatment Information

By ticking the boxes below and submitting this form:

I understand that acuneedling may help by stimulating the body’s natural healing processes, altering nerve signals, and helping manage pain and other symptoms.
I understand the purpose of acuneedling is to provide therapeutic benefit during pregnancy, birth or postnatally.
I understand the procedure involves inserting very thin needles at specific points, and I may feel numbness, dull ache, warmth, or tingling.
I understand none of the points used are close to my baby.
I understand potential risks include bruising, minor bleeding, dizziness, or fainting.
I confirm that I have been provided with clear information about acuneedling (acupuncture using very thin needles or moxibustion) as a complementary therapy provided by a registered midwife.
I will have the opportunity to ask questions at our face-to-face appointment

My Rights

By ticking the boxes below and submitting this form:

I understand that I may withdraw my consent at any time without affecting my care
I understand that acuneedling is a complementary therapy and does not replace medical care or advice
I understand my personal information will be kept confidential and handled according to New Zealand privacy laws
I understand I can access the New Zealand Code of Health and Disability Services Consumers’ Rights here: https://www.hdc.org.nz/your-rights/about-the-code/code-of-health-and-disability-services-consumers-rights

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Consent*

I confirm I have read and understood the information provided about acuneedling.

I give my informed consent to receive acuneedling treatment as described.

I confirm I have disclosed all relevant medical conditions and pregnancy history.

I understand I may withdraw my consent at any time.

I confirm that I have read and understood the Privacy Statement.

I consent to my personal and health information being collected and stored securely for the purposes of my maternity acuneedling care

I understand that I may request access to, or correction of, my information at any time.

Consent*

I confirm I have read and understood the information provided about acuneedling.

Consent*

I give my informed consent to receive acuneedling treatment as described.

Consent*

I confirm I have disclosed all relevant medical conditions and pregnancy history.

Consent*

I understand I may withdraw my consent at any time.

Consent*

I confirm that I have read and understood the Privacy Statement.

Consent*

I consent to my personal and health information being collected and stored securely for the purposes of my maternity acuneedling care

Consent*

I understand that I may request access to, or correction of, my information at any time.