Medical History Form

Medical History Form
Full Name*

First NameLast Name
Email Address*
example@example.com
Date of Birth*

DayMonthYear
Date
Contact Number*
Biological Sex:*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your occupation?*
Are you doing any physical activity/hobby?*
Have you ever been tested for Bone Density?*

YesNo
What were the findings?
Are you smoking?*

YesNo
How many a day?
Have you a Nervous or Brain Diseases? (Paralysis, Movement and / or sensory disturbances, Dizziness, Faintings, Chronic Headaches, Epilepsy, etc.)*

YesNo
Which?
Have you been diagnosed with a Cardiovascular disease? (Heart attack, Cardiac arrest, Chest pain or pressure, Shortness of breath, Heart failure, Arrhythmia, etc.)*

YesNo
What was the Diagnosis?
Have you any Joint / Bone disease? (Arthritis, Osteoporosis, Osteopenia, etc.)*

YesNo
Please specify
Do you have a Herniated / Bulging Discs?*

YesNo
Which segments?
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
What is it?
Are you Pregnant?

YesNo
How many weeks in?*
Are you currently taking any medication?*

YesNo
Please list them.*
Any surgeries I should be aware of? Hospitalization?*

YesNo
What happened?
How did you hear about us?

Friends/FamilyFacebook/instagramGoogleProfessional referalOther
I am aware that the treatment supplied by Sammakko 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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