First name:

Last Name:

Address:

Date Of Birth:

Email:

Home Phone Number:

Mobile Number:

Martial Status:

Pregnant:

YESNO

No Of Dependents:

Profession:

Present Health:

Taking Prescribed Medicines:

Injury Location:

Ongoing Condition:

YESNO

Had An Operation?:

YESNO

Do You Have Any Allergies?:

Do You Have Cancer?:

On a Scale Of 1-10 How Painful Is Your Injury? (0 Being no pain 10 being worst possible pain):

Skin:

Acne VulgarisAcne RosaceaEczemaDermatitisPsoriasisAthlets FootWarts or VerrucasSkin AllergiesOther (Please Specify)


Skeletal & Muscular System:

HeadNeckShouldersElbowArmLower BackHipWristHandFingersLegsKneeLower LegFootAnkleFractures & SprainsArthritisFibrositisOsteoporosisWhiplashSlipped DiscAches & PainsOther (Please Specify)


Cardiovascular System:

ThrombosisPhlebitisHypertensionMedical OedemaHaemophiliaVaricose VeinsCold hand & FeetAnginaArteriosclerosisHaemorrhoidsOther (Please Specify)


Lymphatic System:

InfectionSwellingGlandular FeverLeukaemiaAIDSOther (Please Specify)


Nervous System:

HeadachesMigraineEpilepsyShinglesSciaticaParkinson's DiseaseMultiple SclerosisStrokeDepressionAnxietyTensionInsomniaOther (Please Specify)


Endocrine System:

Thyroid ProblemDiabetes MellitusGoitreAdrenal Gland DisorderOther (Please Specify)


Reproductive System:

Breast LumosPelvice Inflammatory diseaseIrregular Period'sPMTMenopauseH.R.TTestes & Prostates ProblemsOther (Please Specify)


Digestive System:

IndigestionFlatulenceGastric UlcersColitisDiverticulitisHerniaConstipationDiarrhoeaIrritable Bowel SyndromeCirrhosis Of The LiverGall StonesHepatitisVomitingBloatingIOther (Please Specify)


Respiratory System:

Colod & CoughsSinusitisHay FeverBronchitisAsthmaEmphysemaPneumoniaPleurisy"Other (Please Specify) " ]


Urinary System:

CystitisUrethritisNephritisIncontinence ( and Bed Wetting)Kidney Stone" "Other (Please Specify) " ]


Others Not Mentioned Above:


Do You Eat Regular Meals?

YESNOSometimes


Do You Eat In A Hurry?

YESNOSometimes


How Many Glasses Or cups Daily Do You Have Of The Following?

Water | Tea | Coffee | Fruit Juices | Fizzy Drinks | Milk |
Other


Do You Drink Alcohol?

YESNO

How many units do you drink per week?


Are You On Any Diets?

YESNO

If Yes, please specify which diet:


Does your diet contains the minimum intake of five portions of fruit and vegetables per day?

YESNO


Do You Smoke?

YES ( Specify How Many)NO


How Many Hours Of Natural Daylight Do You See Per Day?


Do You Exercise?

YESNO

How many days per week do you exercise?

What Type Of Exercise?


How Are Your Sleep Patterns?

DeepLightDisturbed


What Is Your Skin Type?

DryOilyCombinationSensitive


Ability To Relax?

GoodModeratePoor


What Is Your Stress level On Average On Any Given Day? Please State 1-10 10 Being Most Stressed.


At Work


At Home


How Do You Relax? Please Give Some Examples:


Client Disclaimer

I confirm that as of this date all the information I have given is correct and that I have not omitted any information concerning my health, which should properly be diagnosed. I am wholly responsible for the consequences of any failure by me to do so.

I understand that it is my responsibility to notify the therapist (JM Body Care) of any changes that may affect my treatment either now or in the future.

*Accept - This field is required.

 

 

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