Integrated Health Center Salt Room Intake Form
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1INTEGRATED HEALTH CENTER
Salt Room Intake
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Name___________________________ Date ___________ Referred by_____________________________
Address_________________________________ City__________________ State______Zip____________
Date of Birth______________ Home Phone________________ Cell Phone_________________
Email Address________________________ Emergency Contact_________________ Phone_______________
Informed Consent
The above named client, have requested and agreed to undergo the process of Halotherapy. I have been informed of the potential
benefits, risks, and consequences of Halotherapy, which is unconventional in nature and all my questions, have been answered to
my satisfaction. I am satisfied with and understand the information provided as I acknowledge that Integrated Health Center takes
no responsibility for customers choosing to treat themselves by means of Halotherapy, which has not been evaluated by the Food
and Drug Administration and is not intended to diagnose, treat, cure or prevent any disease. I understand that for all my health
concerns, it is my responsibility to consult an appropriately licensed healthcare practitioner. I further release Integrated Health
Center from any legal ramifications should injury, death, or illness occur as a result of Halotherapy.
I do not have any of the following conditions:
•
Acute stage of respiratory’ diseases
•
Chronic obstructive lung diseases with 3~ stage of chronic lung insufficiency
•
Intoxication
•
Cardiac Insufficiency
•
Bleeding
•
Blood Spitting
•
Hypertension in II B stage
•
Any and all internal diseases in acute stage
•
Kidney Disease (acute stage)
I herby give my consent to participate in the Halotherapy sessions entirely at my own risk.
Signature:__________________________________________ Date:______________________
Current reason for Salt Spa use:___________________________________________________________________
Past Medical History limited to respiratory’ and skin health _____________________________________________
Are you a smoker? ____yes ____no
List any allergies:________________________________________________
Review of Symptoms Checklist (mark all that apply)
___Fatigue
___Headache
___Lumps
___Skin Dryness
___Skin color changes ___Chest pain
___Earache
___Stuffiness
___Discharge
___Sore Tongue
___Swollen glands
___Difficulty breathing
___Itching
___Drainage
___Fainting
___Tingling
___Sore tongue
___Hair/Nail changes
___Tremor
___Hives
___Skin Rash
___Allergies
___Painful breathing
___Decreased hearing
___Numbness
___Tightness
___Weakness
___Sore Throat
___Hay Fever
___Coughing up blood
___Dry Mouth
___Hoarseness
___Stress
___Wheezing
___Decreased hearing ___Ringing in ears
___Depression
___Edema
___Snoring
___Night Sweats
___Shortness of breath ___Trouble sleeping
___Palpitations ___Seizures
___Dizziness
___ Numbness
___Nervousness
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