Hijama Medical Questionnaire

Hijama Medical Questionnaire
Patient Full Name*

First NameLast Name
Patient Age*
Email Address *
example@gmail.com
Contact Number*
Enter a valid cellphone numberFormat: (000) 000-0000.
ID Number*
Your 13 digit Identity Number
Date of Birth*

DayMonthYear
Residential Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Person Responsible for Account*

Full NameContact Number
In Case of Emergency *

Full NameContact Number
YesNo
Do you have ANY Medical Conditions ? List Below... *
Are you currently on ANY Medication ? List Below... *
Do you have High/Low blood pressure ? Specify... *
Do you have any known Cardiovascular problems (abnormal ECG, previous heart attack, etc) ? Specify... *
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
YesNo
Please provide details
Pregnant or currently MenstruatingCancerKeloid, Skin Wounds or LesionsPost SurgerySunburn, Open wounds or FracturesFeverVaricose VeinsPacemakerLupusNone of the above
YesNo
Please provide details
Disclaimer

The SAHS or its subsidiary bodies namely SAHS Practitioners cannot be held legally, physically, mentally, psychologically or financially responsible for any transmission of diseases, death or health-related issues, that may inadvertently occur during the cupping session or be caused by the trained Hijama Practitioner.
Signature*

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Hijama Medical Questionnaire

Disclaimer