Health Questionnaire

Client Health Questionnaire

Zilber's Way - Senior Medical Massage Therapist & Personal Trainer
Full Name *

First Name Last Name
Biological Sex *

Male Female
Birth Date *

Day Month Year
Phone Number *
Address *

Street Address (Including Number)

Street Address Line 2

City State / Province

EIRcode
Please mark all the fields that are relevant to you. A relevant field is when the answer is Yes: *

Have you ever been tested for Bone Density? Are you smoking? Nervous or Brain Diseases? (Paralysis, Movement and / or sensory disturbances, Dizziness, Faintings, Chronic Headaches, Epilepsy, etc.) Cardiovascular disease? (Heart attack, Cardiac arrest, Chest pain or pressure, Shortness of breath, Heart failure, Arrhythmia, etc.) Joint / Bone disease? (Arthritis, Osteoporosis, Osteopenia, etc.) Herniated / Bulging Discs? None of the Above applies to me
Should any of the above be marked, please elaborate: *
Are you aware of any health condition of which you weren’t asked about directly and is important to note prior to the session? *

Yes No
Please Elaborate:
Are you pregnant?

Yes No
What Week?
Are you currently taking any medication? Which? *
Any surgeries I should be aware of? Hospitalization? Why? *
I am aware that the treatment supplied by Zilber's Way isn't a replacement for any conventional treatment and/or GP consultation.
I will not stop medicine use of any sorts without consulting my physician.
I am aware that the therapist is not a doctor, and does not replace any medical consultation.
I hereby state that all my answers are true, and I did not withhold any clinical data from the therapist.
Signature Date

Day Month Year
Date
Signature *

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Client Health Questionnaire