Aqua Detox Consent & Consultation Form/patient Form
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4AQUA DETOX Consent & Consultation Form
Patient Form
Private & Confidential
Cupping & Complementary Medicine Clinic
Successful health care and preventative medicine are only possible when the practitioner has a complete understanding
of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all
information and indicate areas of confusion with a question mark. Thank you.
Date: …………………………
1: Personal Details
Title & Name
Address
Tel
Mob
Email
Date of Birth
Age
Gender
Male/Female
2: Emergency Contact
Name
Tel
Relationship
3: Current Readings
Blood
Pulse Rate
Pressure
4: Contra Indications Check list
Please tick the appropriate responses
[ ]
Do you have a Pacemaker or any other battery-operated/electrical implant
[ ]
Do you have any device placed on/near the heart eg, stent, valves
[ ]
Are you taking any heartbeat regulating medication
[ ]
Are you Pregnant / nursing mother
[ ]
Have you had an Organ transplant
[ ]
Have you an organ removed, especially the colon
[ ]
Do you have a tendency to faint or have blackouts or epilepsy ?
[ ]
Do you have a Psychological case of insanity, psychotic episodes, seizures or rage ?
[ ]
If so, Are you
taking any medication for them, that without them would mentally or physically
incapacitate you (eg: epilepsy , insanity , psychotic episodes, seizures or rage etc.)
[ ]
Do you have any open wounds or cuts on Feet
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