Health Questionnaire

Client Health Questionnaire - Minors

Zilber's Way - Senior Medical Massage Therapist & Personal Trainer
Form Notice

This form relates to any client under 18 years of age and MUST be signed by an apotropos (legal guardian). Please note that the apotropos's presence is require for the session.
Full Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

DayMonthYear
Phone Number (If exists)
Address*

Street Address (Including Number)

Street Address Line 2

CityState / Province

EIRcode
Please mark all the fields that are relevant. 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:
Any medication currently taken? Which?*
Any surgeries I should be aware of? Hospitalization? Why?*
Apotropos Fields

Once the client turns 18 and wish to continue the sessions a new form would be issued to them.
Full Name*

First NameLast Name
Biological Sex*

MaleFemale
Phone Number*
Relation to the client*
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 a 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 about the client from the therapist.
Signature Date*

DayMonthYear
Date
Signature*

Clear
Should be Empty:

Client Health Questionnaire - Minors

Form Notice

Apotropos Fields