NicoMedical Health Screening Form

1
Full Name* This field is required.
First Name
Last Name
2
Best Contact number* This field is required.
3
E-mail* This field is required.
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Post Code
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Emergency Contact Person* This field is required.
6
Date of Birth* This field is required.
Month
Day
Year
7
Height cm* This field is required.
8
Weight kg* This field is required.
9
Sex* This field is required.
Male
Female
10
Are you active on a daily basis?* This field is required.
Yes
No
11
Are you pregnant?* This field is required.
N/A
Yes
No
12
What do you do for a living?
13
Have you been recommended by any of our clients?* This field is required.
Yes
No
14
If YES, please help us reward them:* This field is required.
First Name
Last Name
15
If NOT, how did you hear about NICOMEDICAL?* This field is required.
Friend
Yellow Pages
Advertisement
Visited Us
Other
16
Which of our services are you most interested in?* This field is required.
Gynecologist
Orthopedist
Urologist
General Surgeon
Otorhinolaryngologist
Plastic surgeon
Cosmetologist for facial treatments such as cleansing etc.
Integrated Manual Therapist
Human Movement Specialist
Other
17
If you chose 'Other' in previous question, which services are you interested in?Which medical
Huge
Large
Normal
Small
Ok
Ok
18
Upload all relevant medical results
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
19
Have you ever suffered from...?* This field is required.
Asthma
High or Low Blood Pressure
Epilepsy
Diabetes
Frequent Colds
Dizziness or Fainting
Heart Disease
Shortness of breath
High Cholesterol
Headaches or Migraines
NONE
20
Have any of your first-degree relatives suffered from the following diseases?* This field is required.
Heart Attack
High Cholesterol
High Blood Pressure
Congenital Heart Disease
Diabetes
NONE
21
Have you had surgery in the last two years?* This field is required.
Yes
No
22
If YES, Details...* This field is required.
23
Do you have any injuries?* This field is required.
Yes
No
24
If YES, Details...* This field is required.
25
Do you take any...?* This field is required.
Medications
Supplements
NONE
26
If YES, please list...* This field is required.
27
How would you rate your current physical fitness?* This field is required.
1
2
3
4
5
6
7
8
9
10
Poor
Athlete
28
How would you describe your nutritional habits?
Bad
Good
Optimal
29
Have you ever suffered from any of the following?* This field is required.
Digestive Problems (IBS, Bloating etc)
Allergies
Kidney Problems
Food Intolerances
NONE
30
Do you have Travel insurance?* This field is required.
YESNO
31
If YES, Details...* This field is required.
Huge
Large
Normal
Small
Ok
Ok
32
Travel insurance is highly recommended. We will contact you to request travel insurance.
33
Do you have Life insurance?
YESNO
34
If YES, Details...
Huge
Large
Normal
Small
Ok
Ok
35
IF NOT, would you like us to help you apply for Life Insurance?
YESNO
36
We will contact you to request Life Insurance.
37
Upload a copy of a valid Identification* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
38
Please read the following Terms and Conditions

1.) CANCELLATIONS

Cancellations must be made a minimum of 24 hours prior to the scheduled session.

Sessions cancelled less than 24 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS

Each session will have a duration of 45 minutes. Sessions will not be extended (unless time is available) due to client tardiness or due to interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE PROVIDED IS CORRECT

All information on this form is correct and to the best of my knowledge and belief. I have sought and followed the necessary medical advice. I understand that all information provided will be kept confidential.
39
40
I AGREE to the above terms and conditions.* This field is required.
Yes
No
41
* This field is required.
42
Math testHere you confirm by entering a number that you are a human user
Should be Empty: