Intake Form

  • Intake Form

  • Birth Day
     - -

  • Please answer the following questions to the best of your ability

  • Do you exercise?
  • Have you been using soft drugs, alcohol or nicotine latley?
  • Have you undergone any training in providing care (emotional / physical)?
  • Have you received psychological or physical treatments?
  • Are you receiving any other health treatments?

  • 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*
  • High / low blood pressure*
  • Any respiratory disease*
  • Cancer and / or other tumor*
  • diabetes*
  • Coagulation problems*
  • Excess lipids in the blood*
  • Kidney / urinary tract diseases*
  • Liver / gallbladder disease*
  • Gastrointestinal diseases*
  • Hormonal problems (menstrual cycle / thyroid)*
  • Allergies*
  • ENT problems*
  • Skin and / or fungal diseases*
  • Eye problems*
  • Fractures / sprains / injuries*
  • pain / arthritis*
  • Osteoporosis*
  • epilepsy*
  • A stroke in the last decade*
  • surgery*
  • Fever / flu / any kind of illness*
  • Are you pregnant?*
  • Are you taking medications / supplements?*
  • Diseases in the family*
  • Are you taking any medications for a problem you came to this treatment for?*
  • 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?*

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

    My 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.
  • Should be Empty: