clientConsultation Form Client's Name: * First Name Last Name Email Address * Please write down your active email address so that, we can easily contact you! :) Address Tel No. & Mobile No. Include your country code Birth Date * MM DD YYYY GP Details: * Are you pregnant? YES or NO? * If yes, how many months? Do you have any dependents? * Reasons for Visit? * Short Term Medical History? * Long Term Medical History? * Medication including Herbal Medicine/Homeopathy? No/ Yes? * Do you have any Allergies such as wheat or pollen etc.? * Please list down all your allergies. How do you feel TODAY? * Explain your feelings for today! FAMILY HISTORY * Age of Parents, if living: Any hereditary illness that you can think of such as: Cancer Diabetes Stroke Heart Disease TB Nervous Breakdown Asthma Hepatitis None of the above Give Details if Possible: Number of siblings if there is any and where do you come in the family: YOUR HEALTH & CONSTITUTION: RESPIRATORY & CARDIOVASCULAR Note: Please tick the box if you ever experience any of the following - sometimes or always. Sore Throat Coughing Up Blood Nasal Problems Cough Nose Bleed Asthma or Wheezing Pneumonia Bronchitis Shortness of Breath High Blood Pressure Irregular Heart Beat Dizziness Chest Pain or Pressure Leg Cramps Cold Hands/ Cold Feet None of the above YOUR HEALTH & CONSTITUTION: GASTROINTESTINAL * Note: Please tick the box if you ever experience any of the following - sometimes or always. Indigestion Gall Stones Abdominal Pain or Cramps Diarrhea Constipation Blood in Stool Heartburn Excess Appetite Increased Appretite Excess Thirst Nausea and Vomitting Colitis Diverticulitis Belching or Burping None of the above YOUR HEALTH & CONSTITUTION: SKIN Note: Please tick the box if you ever experience any of the following - sometimes or always. Ulcerations Rash or Dry Skin Oedema Dermatitis Acne Psoriasis Eczema None of the above YOUR HEALTH & CONSTITUTION: MUSCULOSKELETAL * Note: Please tick the box if you ever experience any of the following - sometimes or always. Back Pain Curvature of the Spine such as Scoliosis Painful Joints Break bones easily Stiff Joints Arthritis Muscle Pain or Cramps None of the above YOUR HEALTH & CONSTITUTION: GENITOURINARY * Note: Please tick the box if you ever experience any of the following - sometimes or always. Frequent Urination Painful Urination Bloody Discharge Venereal Disease Pain in the Genital Area Decrease Sex Drive None of the above YOUR HEALTH & CONSTITUTION: Males Only Note: Please tick the box if you ever experience any of the following - sometimes or always. Prostate Problems Pain in the Testicles None of the above YOUR HEALTH & CONSTITUTION: Females Only Note: Please tick the box if you ever experience any of the following - sometimes or always. Pre-Menstrual Pain Irregular Menstrual Pain Irregular Menstrual Cycle Swelling or Pain in the Breast None of the above YOUR HEALTH & CONSTITUTION: MISCELLANEOUS * Note: Please tick the box if you ever experience any of the following - sometimes or always. Jaundice Hepatitis Memory Loss Hearing Loss Intolerance to weather change Ringing in the Ears Fever Insomnia Chills Night Sweats Kidney Stones None of the above LIFESTYLE Is there anything else you'd like to tell me about your medical health or lifestyle? All the information that I've given is true. The treatment has been explained to me and I consent the treatment as explained. * AGREE NOT AGREE Please tell us or elaborate where you are feeling pain on your body, both front and back. * Thank you!