• Medical History Form

  • Form Notice

    This form relates to any client under 18 years of age and MUST be signed by a legal guardian. Please note that the legal guardian's presence is require for the session.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Biological Sex:*
  • Have you ever been tested for Bone Density?*
  • Are you smoking?*
  • Have you a Nervous or Brain Diseases? (Paralysis, Movement and / or sensory disturbances, Dizziness, Faintings, Chronic Headaches, Epilepsy, etc.)*
  • Have you been diagnosed with a Cardiovascular disease? (Heart attack, Cardiac arrest, Chest pain or pressure, Shortness of breath, Heart failure, Arrhythmia, etc.)*
  • Have you any Joint / Bone disease? (Arthritis, Osteoporosis, Osteopenia, etc.)*
  • Do you have a Herniated / Bulging Discs?*
  • Are you aware of any health condition of which you weren’t asked about directly and is important to note prior to the session?*
  • Are you Pregnant?
  • Are you currently taking any medication?*
  • Any surgeries I should be aware of? Hospitalization?*

  • Legal Guardian Fields

    Once the client turns 18 and wish to continue the sessions a new form would be issued to them.
  • Biological Sex*
  • Format: (000) 000-0000.

  • 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
     - -
  • Should be Empty: