The forms

Health History Form

Name

First Name

Last Name

Session date

Please list the date of the session you've booked.

What would you like me to call you?

Is there another name you go by other than your first name?

Gender / Pronouns

Date of birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name and contact information of your physician or health care provider.

(if you don't have a regular health care provider, please put N/A)

Are you currently taking medications?

(Y/N - If yes, please provide details)

Please give details of recent and relevant medical treatment, operations or family history, etc.

Do you have Epilepsy?

(Y/N- If yes, please give details)

Are you pregnant of trying to become pregnant?

(Y/N - If yes, please give details)

Do you have any metal medical implants? This include screws or plates from a broken bone.

(Y/N - If yes, please give details)

Do you have a deep vein thrombosis in the leg or known thrombi?

(Y/N- If yes, please give details)

Do you have any open or unhealed wounds?

(Y/N - If yes, please give details)

Do you have any acute swelling, infl ammation or tumors?

(Y/N - If yes, please give details)

Have you recently had any surgery?

(Y/N - If yes, please give details)

Do you have cartoid atherosclerosis?

(Y/N - If yes, please give details)

Do you have eczema?

(Y/N- If yes, please give details)

Do you have any diseased veins?

(Y/N- If yes, please give details)

Do you have any other inflammatory skin disorders?

(Y/N- If yes, please give details)

Do you have any other inflammatory processes generally associated with fever?

(Y/N- If yes, please give details)

Do you have a cardiac pacemaker, artificial heart valve, defibrillator or cardiac arrhythmias?

(Y/N- If yes, please give details)

Do you have a shunt?

(Y/N- If yes, please give details)

Do you have a stent?

(Y/N- If yes, please give details)

Do you have a deep brain stimulation device (DBS)?

(Y/N- If yes, please give details)

Have you had whiplash in the last 3 days?

(Y/N- If yes, please give details)

Please type your full name indicating that all information given is accurate and correct at the time of writing.

Next up: Physical self-assessment

The forms

Health History Form

Location

Hours

Contact