Transformational You
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Parent/Guardian Waiver for Minors
Family Healing Survey Form
Home
About
Our Mission
Our Founder
Testimonials
Videos
Experience
Medical Spiritual Healing
Healing Family Dynamics
Hijama Therapy
Transformational You
Getting to the heart of the issue
Services
Connect
Forms
Medical Intake Form
Emotional Intake Form
Emergency Contact Form
Waiver and Release of Liability Form
Parent/Guardian Waiver for Minors
Family Healing Survey Form
Medical Intake Form
Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Gender
Male
Female
Martial Status
Single
Married
Widowed
Divorced
Seperated
Occupation
Do you Smoke?
Yes
No
Do you drink Alcohol?
Yes
No
Do you have any children? If so, how many?
How would you describe your current overall health condition?
List any prescriptions, over-the-counter medications, or recreational drugs you are currently taking.
List any supplements, vitamins or herbs you are currently taking.
Describe the quality and length of your nightly sleep.
Have you ever been treated for any of the following?
Blood Pressure
Poor Circulation
Breathing problems like Asthma or Emphysema
Stroke
Heart Murmur
Anxiety
Diabetes
High Cholesterol
Angina or chest discomfort
Heart Attack
Thyroid Problems
Rheumatoid Disorder
Stomach Problems or Ulcers
Hepatitis
Kidney Problems
Anemia
Please list any other medical conditions:
Do you have any of the following symptoms?
Weight Loss
Passing out episodes
Headaches
Palpitations or rapid beating heart
Changes in bowel habits
Seizures
Shortness of breath at rest
Nausea/vomiting/diarrhea
Temporary blindness in one eye
Unusual shortness of breath on exertion
Vomiting blood or blood in your bowel movements
Numbness in arm or leg
Difficulty breathing at night
Painful urination
Leg pain/fatigue with walking
Chronic cough
Excessive bleeding or Easy bruising
Abdominal pain
Chest pain or pressure at rest
Chest pain or pressure on exertion
Anxiety
Please list any other relevant medical information below.
Including hospitalizations/surgeries/accidents/injuries (date/year/complications?):
Thank you!