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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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