Confidential Client Health History Form
Medical History & Information
Please complete as accurately as possible. A separate Consent form for treatment is required prior to your first visit.
Name
First Name
Last Name
Email
example@example.com
Date of birth
-
Day
-
Month
Year
Date
Occupation
In the past have you ever had any of the following: (please select YES if you have previously had this and CURRENT if you are still experiencing this illness or injury)
Yes
No
Current
Cardiovascular disease
High blood pressure/cholesterol
Blood disorders/diseases
Diabetes
Contagious diseases
History of Cancer
Asthma
Epilepsy
Pregnant
Elbow or wrist injury
Knee injury
Ankle injury
Shoulder injury
Hip injury
Skin conditions
Varicose veins
Broken Skin
If you are pregnant, please indicate number of weeks
Please provide details of injuries to your back, neck, shoulders, elbows, wrists, hips, knees or ankles in your medical history:
Please list any prescribed medications being taken and what conditions they are taken for:
Please give any relevant surgical procedures that you have had (and what year):
Please list any areas for your therapist to avoid during treatment:
Thank you for completing this form. Please select submit to finalise.
Submit
Should be Empty: