Client Record Form

CLIENT DETAILS

 


GP DETAILS

 


EMERGENCY DETAILS

 


MEDICAL HISTORY

 


Skin disorders (Eczema)FeverRecent OperationsInflammationSprains and StrainsCutsBruisesBurnsFracturesInfection (Septicaemia)BursitisVaricose VeinsSwelling (required)

 


CancerCardiovascular Disease (Heart)Undiagnosed LumpsEpilepsyNervous System DisordersLymphatic System DisordersAutoimmune Disorders (HIV and AIDS)High/Low Blood PressurePneumoniaThrombosis (DVT) (required)

 


Medically Weak SkinBone, TissuesHaemophiliaPregnancyUndiagnosed Musculoskeletal Disorders / Asthma / AllergiesHeadachesSinusitisDiabetesSubstance Addiction

 


ANY OTHER CONDITIONS:

 

 

 

 


 

CONSENT

 

 

I AGREE

 

 


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