Please list all conditions currently monitored by a health care provider__________________________________ Please describe any surgeries you’ve had___________________________________________________________ Please circle any of the following you’re wearing today: Contact lenses Dentures Hairpiece Hearing Aid Please check any conditions you currently have or have had in the past. Explain below including current or past treatments. ☐Allergies ☐Hearing loss ☐Arthritis ☐Heart disease ☐Asthma ☐High or low blood pressure ☐Anxiety ☐Hypoglycemia (low blood sugar) ☐Benign ☐Implants tumors (silicone, saline, metal pins etc.) ☐Blood ☐Insomnia Clots (DVT) ☐Broken ☐Joint Bones replacement(s) ☐Bursitis ☐Memory loss ☐Cancer ☐Numbness/tingling in shoulders, arms, fingers ☐Circulatory ☐Numbness/tingling problems in legs, feet, toes ☐Cold ☐Osteoporosis/Osteopenia or flu within past 48 hrs. ☐Concentration ☐Sciatica difficulties ☐Concussion ☐Scoliosis ☐Confusion ☐Seizures ☐Congestive ☐Sinus heart failure infections (recurring) ☐Contagious ☐Spasms/cramps diseases ☐Depression ☐Spinal conditions ☐Diabetes ☐Stiff or painful joints ☐Disc ☐Stroke problems (bulge or herniation) ☐Edema ☐TMJ (swelling/water retention) ☐Fatigue ☐Tendonitis ☐Frequent ☐Thyroid falls or sudden “clumsiness” dysfunction ☐Headaches ☐Varicose (frequent) veins ☐Vision problems (sudden blurry or double) Explain:_______________________________________ Explain:______________________________________ Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my
Please list all conditions currently monitored by a health care provider__________________________________ Please describe any surgeries you’ve had___________________________________________________________ Please circle any of the following you’re wearing today: Contact lenses Dentures Hairpiece Hearing Aid Please check any conditions you currently have or have had in the past. Explain below including current or past treatments. ☐Allergies ☐Arthritis ☐Asthma ☐Anxiety ☐Benign tumors ☐Blood Clots (DVT) ☐Broken Bones ☐Bursitis ☐Cancer ☐Circulatory problems ☐Cold or flu within past 48 hrs. ☐Concentration difficulties ☐Concussion ☐Confusion ☐Congestive heart failure ☐Contagious diseases ☐Depression ☐Diabetes ☐Disc problems (bulge or herniation) ☐Edema (swelling/water retention) ☐Fatigue ☐Frequent falls or sudden “clumsiness” ☐Headaches (frequent) Explain:_______________________________________ ☐Hearing loss ☐Heart disease ☐High or low blood pressure ☐Hypoglycemia (low blood sugar) ☐Implants (silicone, saline, metal pins etc.) ☐Insomnia ☐Joint replacement(s) ☐Memory loss ☐Numbness/tingling in shoulders, arms, fingers ☐Numbness/tingling in legs, feet, toes ☐Osteoporosis/Osteopenia ☐Sciatica ☐Scoliosis ☐Seizures ☐Sinus infections (recurring) ☐Spasms/cramps ☐Spinal conditions ☐Stiff or painful joints ☐Stroke ☐TMJ ☐Tendonitis ☐Thyroid dysfunction ☐Varicose veins ☐Vision problems (sudden blurry or double) Explain:______________________________________ Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my