Medical & Wellness Questionnaire

  • Medical & Wellness Questionnaire

    Confidential - Required before any sessions

  • Client Information

  • Date of Birth (DOB)*
     - -
  • Format: 0000 000 000.
  • Format: 0000.
  • Format: 0000 000 000.

  • Client Background and Wellness Assessment

  • 1- How Did You Hear Bout us?*
  • 2- Were you referred by someone?*
  • Format: 0000 000 000.
  • 3- Please select your age group*
  • 4- Industry you work in*
  • 5- What services are you coming for today?*
  • 6-What is the main reason for your visit?*
  • 7- Where do you currently experience pain?*
  • 8- Pain Severity (0 = No pain, 10 = Severe pain you can’t tolerate):*
  • 9-Duration of the Pain:*
  • What are your goals from our wellness therapies?*

  • Medical History

    Please answer honestly. Tick Yes/No and provide details if Yes.
  • 1. Are you feeling well today (no fever, flu, or chest infection)?*
  • 2. Have you had any recent surgery or injuries that might make sitting in a massage chair or HBOT uncomfortable?*
  • 4. Do you have any implanted medical devices (e.g., pacemaker, insulin pump, joint replacements under 3 months)?*
  • 5. Do you have any respiratory or lung conditions?*
  • 6. Do you have any ear or sinus issues?*
  • 7.Do you have any skin sensitivity, wounds, or metal allergies where the grounding bracelet will be placed?*
  • 8.Do you have claustrophobia? (HBOT Question)*
  • 9.Are you currently under medical care or taking medication?*
  • 10. Are you currently pregnant or breastfeeding?*
  • 11. Is there anything else about your health or comfort we should know before your session?*

  • Acknowledgement

  • Liability Waiver

  • • I hereby release, indemnify, and hold harmless Wellness Pillars Club, its directors, staff, and contractors from any liability, claims, or damages arising from my participation inHGZ sessions, except where caused by their proven negligence or as otherwise required by law.


    • I understand that participation is voluntary and that I may stop at any time.


    • I acknowledge that results vary between individuals and no guarantee of outcome has been made.

     

  • Consent

  • • I have read and understood this form.

    • I declare that the information provided is true and complete.

    • I consent to participate in Hydro Ground Zero (HGZ) sessions at Wellness Pillars Club.

  • Should be Empty: