Clone of Medical History Form

Health Questionnaire

This form is used for us to get to know you better. The more details you give us, the more specific the treatment and help we can provide.
Full Name*

First NameLast Name
Email Address*
example@example.com
Date of Birth*

DayMonthYear
Date
Contact Number*
Biological Sex:*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your occupation?*
Are you doing any physical activity/hobby?*
Have you ever been tested for Bone Density?*

YesNo
What were the findings?
Are you smoking?*

YesNo
How many a day?
Have you a Nervous or Brain Diseases? (Paralysis, Movement and / or sensory disturbances, Dizziness, Faintings, Chronic Headaches, Epilepsy, etc.)*

YesNo
Which?
Have you been diagnosed with a Cardiovascular disease? (Heart attack, Cardiac arrest, Chest pain or pressure, Shortness of breath, Heart failure, Arrhythmia, etc.)*

YesNo
What was the Diagnosis?
Have you any Joint / Bone disease? (Arthritis, Osteoporosis, Osteopenia, etc.)*

YesNo
Please specify
Do you have a Herniated / Bulging Discs?*

YesNo
Which segments?
Are you aware of any health condition of which you weren’t asked about directly and is important to note prior to the session?*

YesNo
What is it?
Are you Pregnant?

YesNo
How many weeks in?*
Are you currently taking any medication?*

YesNo
Please list them.*
Do you have any scars? Surgical or non-surgical*

YesNo
What happened?
How did you hear about us?

Friends/FamilyFacebook/instagramGoogleProfessional referalOther
I am aware that the treatment supplied by Zenith Morphosis, and the therapists practicing within, is not 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 therapists are not medical doctors, and do not replace any medical consultation.
I hereby state that all my answers are true, and I did not withhold any clinical data from the clinic.
Signature Date

DayMonthYear
Date
Signature*

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Health Questionnaire