Health Questionnaire

Client Health Questionnaire

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

First NameLast Name
Biological Sex*

MaleFemale
Birth Date*

DayMonthYear
Phone Number*
Address*

Street Address (Including Number)

Street Address Line 2

CityState / 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?*

YesNo
Please Elaborate:
Are you pregnant?

YesNo
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

DayMonthYear
Date
Signature*

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Client Health Questionnaire