Have you ever had: circle yes or no) High blood Yes No Arthritis/Osteoarthritis pressure Heart Yes No Osteoporosis Disorders High Yes No Cancer Cholesterol Lung Yes No Pacemaker Disorders Circulation Yes No Are you pregnant? Disorders Allergies to tapes Dizzy Spells Yes No or lotions? Seizures Yes No Recent Weight Loss Diabetes Yes No SIGNATURE: ________________________________________ DATE:______________________________
Have you ever had: circle yes or no) High blood pressure Yes No Arthritis/Osteoarthritis Heart Disorders Yes No Osteoporosis High Cholesterol Yes No Cancer Lung Disorders Yes No Pacemaker Circulation Disorders Yes No Are you pregnant? Dizzy Spells Yes No Allergies to tapes or lotions? Seizures Yes No Recent Weight Loss Diabetes Yes No SIGNATURE: ________________________________________ DATE:______________________________