Medical Disclosure Forms

Della Luce

Medical Questionnaire Disclosure Form

Medical health questionnaire disclosure form

You can download the link and print out to fill in. Thank you.

Name:

Surname:

D.O.B:

Address:

Post Code

Email:

Tel:

Occupation:

In order to carry out the safest and most effective and beneficial treatment for you, it is necessary to ask the following questions. Please read carefully and answer all the questions as honestly as you can. Please tick either Yes or No where it is necessary.

Do you have or are you currently affected by any of the following conditions?

YES

NO

Any form of infection, disease or fever:

Are you under the influence of recreational drugs or alcohol.

Female (only) Are you pregnant

Diabetes

Asthma

High blood pressure

Low blood pressure

Trapped/pinched nerver

Varicose veins

Epilepsy

Cardiac patient.

Depressed immune system

Medication affected by heat.

Eczema

Shingles

Heart conditions.

Nervous system dysfunction.

Blood condition.

Whiplash

Cancer

Acute rheumatism

Osteoporosis.

Arthritis.

Undiagnosed.

Recent operations.

Coeliac disease

Lactose intolerant.

Any mental health issues.

Are you receiving any other form of complementary treatments?

Are there any other diagnosed form of conditions being treated by a GP or other specialist or therapists?

Signature:

Date:

 

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