Confidential Health History
Name Contact phone Contact Email
Occupation
Complimentary Therapy History
General
well being – Physically/Emotionally/Mentally
Diet/Indigestion/Fluids/Urination/Bowel movements/Weight loss – gain
Smoking/Alcohol/Rec drugs/Tiredness/Headaches/Dizziness/surgery within the last 12 months
Current key
stressors in life
Medication
Possible contra indications depending on therapy you are receiving
Do
you have or are you: (P
or
O)
£
Infectious skin conditions and diseases (like impetigo)
£
Under influence of alcohol and/or drugs (at least 12h before)
£
Feeling
physically
unwell
e.g. high temperature, a cold
or the flu
£ History of thrombosis
£
Recent head or neck injury
£
Active or swollen arthritis
£
Heart or circulatory conditions, high or low blood pressure
£
History of cancer
£
Osteoporosis
£
Diabetes
£
Asthma
£
Kidney infections/disorders OR any other ailments of the internal organs
£ Nervous or psychotic conditions
£
AIDS or HIV
£
Epilepsy
£
Bruising, inflammation, pain, cuts, abrasions, sunburns, scar tissue,
tenderness,
swelling,
£
Allergies/skin sensitivities
£
Excessive sweating
£
Hernia
£
Recent fractures, strains or sprains, back pain
£
Areas of localised skin disorders such as verucca, athletes foot,
psoriasis, eczema or dermatitis
£
Varicose veins
£
Pregnant
£
Depression
£
Anxiety attacks
Methods of
exercise/relaxation
Site of
Pain
Declaration
-
I have
been informed of contraindications and possible after effects of
therapy
-
The
medical history/symptom list is accurate to the best of my knowledge
-
I
understand that any advice or therapies given is complimentary and
does not provide a medical diagnosis and is no substitute for
necessary medical treatment
Name
Signed
Date
(client)