History Medical FormPlease enable JavaScript in your browser to complete this form.Have you ( or anyone you have recently visited ) tested positive with COVID19? *YesNoFirstLastEmail *Phone *AddressGender *MaleFemaleAny Special Disabilities / Needs?Any Illnesses or concerns?Are you taking any medicationYesNoDo you have any allergies / Asthma?YesNoAny recent surgeries?YesNoAre you diabeticYesNoAre you on any blood thinners?YesNoAre you pregnant or intending to get pregnant?YesNoDo you have a bleeding disorder?YesNoBleeding Gums, Joints, nosebleed?YesNoExcessive menstruation, blood in stool?YesNoAnemia due to any cause?YesNoAllergies to Latex? *YesNoHeart Disease?YesNoCancer (What type)?YesNoHigh Blood Pressure (Hypertension)?YesNoHIV, Hepatitis B or C? *YesNoRash, Cuts, Blisters, Open Wounds?YesNoHistory of fainting?YesNoAny Blood Test / Donated blood recently?YesNoAny Blood Test / Donated blood recently? *YesNoSuffering from Migraines / Headaches?YesNoSuffering from Depression?YesNoAre you on Hormone Therapy?YesNoAre you on contraceptive medications?YesNoDo you have any OBGYN issues?YesNoMetaphysical Issues (Jinn, Seher, Evil Eye)?YesNoDo you smoke?YesNoDo you use drugs?YesNoCheck ALL that applies:DiarrheaIndigestionConstipationHeartburnDid you discuss with your Primary Physician regarding Wet Cupping and has he/she advised you to avoid it?YesNoprimary docHow did you hear about Hijama *WebsiteFrom Family / FriendFlyerAt the Masjid bulletinOtherInstagramFacebookWhat is the main reason why you wish to have Hijama done today? *HealthSomething NewPain ReliefIs there anything in particular you hope to improve with Hijama?Submit
