Treatment Waver

1.

Client Health Record

First Name*

Last Name*

Company

Address*

City*

State*

Postal Code*

Country*

Email*

Day Phone*

Evening Phone

Date of Birth:

In case of emergency:

Telephone:

2.

General & Medical Information

Occupation:

Height:

Weight:

Male

Female

Are you basically in good health

Yes

No

Has there been any change to your health in the past year?

Yes

No

If so, please explain:

Physician:

Telephone:

If you answer "yes" to any of the following questions, please explain as clearly as possible.

Check all that apply

Do you suffer from acne?

Do you have allergies?

Specify:

Do you have arthritis?

Do you have high blood pressure?

if yes, what medication are you taking?

Do you suffer from epilepsy or seizures?

Do you suffer from claustrophobia?

Do you have varicose veins or distended capillaries?

Do you have any contagious diseases?

Do you have heart disease?

Do you have diabetes?

Do you have asthma?

Have you ever had or are you being treated now for cancer?

Please explain:

Do you wear dentures?

Do you have a pacemaker?

Are you currently being treated by a physician for any condition?

Please explain:

Do you have any other medical condition I should know about?

Are you taking any medications (including non-prescription drugs)

Are you using any of the following products?

Your health

How much water do you drink a day?

Glasses

Do you exercise regularly?

Yes

No

How would you describe your overall level of stress?

Low

Medium

High

Comments:

Terms and Conditions

I agree that the information I provided is correct to the best of my knowledge and agree to the terms and conditions of thenaturalhealthspa.com.

I have read and accept these terms and conditions.

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Client Health Record

Date of Birth:

In case of emergency:

Telephone:

Occupation:

Height:

Weight:

Are you basically in good health

Has there been any change to your health in the past year?

If so, please explain:

Physician:

Telephone:

Check all that apply

Specify:

if yes, what medication are you taking?

Please explain:

Please explain:

Do you have any other medical condition I should know about?

Are you taking any medications (including non-prescription drugs)

Are you using any of the following products?

How much water do you drink a day?

Do you exercise regularly?

How would you describe your overall level of stress?

Comments:

Terms and Conditions