Personal Health Information

Client Name:  _________________________________________Today’s Date:______

Address: _______________________________________________________________

Preferred Telephone: ____________________               Email: __________________

 Cell Phone: ____________________________

Occupation:_______________________ Birth Date:__________  Referred by:_____

What are your goals for your treatment?____________________________

1.      How would you describe your general health?

2.      Are you presently under a doctor’s or therapist’s care?  _____If so, for what?

Please list your current symptoms:

3.      Please list any medications or supplements you take on a daily basis, and note what they are for.  Please also list any side effects, if any.

4.      Do you have any allergies?                     If so, to what?

5.      Please circle any of the following conditions which you currently have or have experienced in the past, indicating the dates at the right.  Some may be contraindications for massage. 

Systemic Infections:  Mononucleosis_____ Hepatitis_____Other virus ______________

Cardiovascular:          Varicose veins_____  Phlebitis ____ __Stroke_____Blood clots_____

                                    Acute inflammation _____     Heart Attack____ Heart disease _____

                                    High blood pressure _____    Low blood pressure _____

                                    Other _________________________________________

Musculoskeletal:       Whiplash _____          Low back pain____    Strain/sprain _____

                                    Broken Bones____    Osteoporosis _____   Scoliosis ____

            Foot Pain _____         Torn Ligaments/cartilage/tendons_____     

Arthritis ____ Other____________________

Neurological:              Sciatica _____            Headaches ______     Slipped Disc______

                                    Numbness/weakness/coldness in limbs _______Other_______

Skin:                           Eczema____               Burns_____    Other __________________

Endocrine:                  Diabetes ______        Hypoglycemia_____  Other___________

Respiratory:               Emphysema____   Hay Fever ____ Asthma ____Other_________

Reproductive:            Menstrual cramps_____        PMS _____       Prostatitis _____

                                    Other________________________________________________

Digestive:                   Constipation____            Diarrhea _____     Colitis ____                                                                Crohn’s Disease _____  Other ___________________________

Urinary                       UTIs _____     Other________________

Cancer                        Please describe with dates:_______________________________

Surgery                       Please describe with dates:_______________________________

Other                          Please describe any other conditions (with dates) ____________

                                    ______________________________________________________

It is my choice to receive Qigong, a treatment being given for the well-being of my body and mind.  I agree to communicate with my practitioner if I ever feel my well-being is being compromised.  I understand that Qigong practitioners do not diagnose illness, disease or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals or perform spinal thrust manipulations.  I acknowledge that Qigong is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service.  I have stated all medical conditions that I am aware of and will update the Qigong practitioner on any changes in my health status.  I understand that Qigong sessions are strictly therapeutic and non-sexual; inappropriate behavior will result in termination of the session. 

____________________________________     ____________________________________

Client Signature                                                   Date