BBVJ Client Medical History Form

Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
E-Mail*
example@example.com
Birth Date*

MonthDayYear
Age*
Height *
Weight *
Desired Treatment*
Emergency Contact *

First NameLast Name
Emergency Contact Relationship*
Emergency Contact Phone Number
Please enter a valid phone number.
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverLow/High Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney Disease/DysfunctionLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaHeadaches/MigrainesJoint ReplacementNeurotherapyFibromyalgiaStrokeBlood ClotsNumbnessSprains/StrainsNone of the Above
Are there any other conditions not listed above?
Explain any conditions you have marked above:
Do you have any allergies (including latex and coconut oil) or sensitivities?

YesNoNot sure
Have you ever had, or currently have a history of unusual reactions or problems with TOPICAL anesthesia (e.g. anesthetic creams aand gels) resulting in rashes or other symptoms?

YesNo
If yes, please explain:
Are you taking any medications?

YesNo
If YES, please list all medications that you are currently taking or have used in the past 6 months:
Please list all naturopathic, health food supplements and vitamins:
Include other comments regarding your Medical History
Are you currently pregnant?

YesNo
How Many Days of the Week Are You Active?

Never1-2 days3-4 days5+ daysEveryday
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

YesNo
If YES, for how often?:
What are your fitness goals?
Please check if you agree.*

I acknowledge that I have disclosed my complete medical history and the above is an accurate representation of my medical status. By signing below, I agree that all the information about is true.
Your Signature

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Date

MonthDayYear
Date
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