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Client Medical Consultation Form

Asthma / Breathing Difficulties

Back Problems

Cancer

Chemotherapy / Radiotherapy

Diabetes

Epilepsy

Eye Disorders

Bacterial/Viral/Fungal Infections

Hay Fever

Heart Condition

Hepatitis

Hernias

High / Low Blood Pressure

Pacemaker

History of Thrombosis/Embolism

HIV / AIDS

Hormone Imbalance

Hysterectomy

Mental illness

Allergies

Muscle / Joint Disorder

Pregnancy

Recent Injuries / Fractures

Recent Surgery

Skin Diseases / Disorders

Thyriod Problems

Deep Vein Thrombosis

Kidney Disease / Disorder

Undiagnosed Lumps

Other

Please tick the medical conditions that apply to you:

Are you currently taking any medication?

Blood Thinners

HRT / Contraception

Retinoids / Roaccuntane

Steriods / Anti Inflammatory

Antibiotics

Blood Pressure Medication

Vitamins

Anticonvulsants

Nonsteriodal Anti-Inflammatory

Angiogenesis Inhibitors

Antiplatelet / Aspirin

Other

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