Intake Form

I hereby declare that:

I received an explanation regarding the nature of the treatment I am about to receive at my request.

If I suffer from the following diseases: cardiovascular disease, malignant disease, osteoporosis, diabetes, or another disease that impairs function, I declare that I am under medical supervision.

I undertake that in the event of a change in health status, one of the above diseases or conditions will appear or I will start medication and report it to the therapist without delay.

If I do not report the above and I am harmed in any way during or as a result of the treatment, I will be fully responsible and I or anyone in my power will have no claim in this regard against Hila Kay.

I am aware that complementary medicine treatment is not a substitute for medical and/or psychological treatment and/or any conventional medical consultation and that I do not intend to discontinue any pharmacological treatment without consulting my attending physician.

?Do you suffer from one of the problems mentioned here

Cardiovascular disease*

yesno

High / low blood pressure*

yesno

Any respiratory disease*

yesno

Cancer and / or other tumor*

yesno

diabetes*

yesno

Coagulation problems*

yesno

Excess lipids in the blood*

yesno

Kidney / urinary tract diseases*

yesno

Liver / gallbladder disease*

yesno

Gastrointestinal diseases*

yesno

Hormonal problems (menstrual cycle / thyroid)*

yesno

Allergies*

yesno

ENT problems*

yesno

Skin and / or fungal diseases*

yesno

Eye problems*

yesno

Fractures / sprains / injuries*

yesno

pain / arthritis*

yesno

Osteoporosis*

yesno

epilepsy*

yesno

A stroke in the last decade*

yesno

surgery*

yesno

Fever / flu / any kind of illness*

yesno

Are you pregnant?*

yesno

Are you taking medications / supplements?*

yesno

Diseases in the family*

yesno

Are you taking any medications for a problem you came to this treatment for?*

yesno

Do you know of a health condition that you were not asked about explicitly in this questionnaire, which it is important that I know about?*

yesno

Sessions are by appointment only.Please try to arrive 5 – 10 minutes before your scheduled appointment to allow time to decompress before your bodywork. The time that you schedule is reserved especially for you. Please be kind enough tocall or message 24 hours in advance should you need to reschedule your appointment. If you miss an appointment with less than 24 hours notice, you will be responsible for the fullcharges of the session.*

I agree and accept this policy

I declare that the details in this questionnaire form and the health condition in this statement are complete and correct.

My Signature:

signature*

I want to recieve exercises to establish relaxation in my body, to reduce pain and stay up to date when additional content is ready.

yesNo, thanks