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Medical Form

Please fill out this medical history form to the best of your knowledge prior to your appointment. All appointments require this form to be completed.

Have you ( or anyone you have recently visited ) tested positive with COVID19? *

Yes
No

First

Last

Email *

Phone *

Address

Gender *

Male
Female

Any Special Disabilities / Needs?

Any Illnesses or concerns?

Are you taking any medication

Yes
No

Do you have any allergies / Asthma?

Yes
No

Any recent surgeries?

Yes
No

Are you diabetic

Yes
No

Are you on any blood thinners?

Yes
No

Are you pregnant or intending to get pregnant?

Yes
No

Do you have a bleeding disorder?

Yes
No

Bleeding Gums, Joints, nosebleed?

Yes
No

Excessive menstruation, blood in stool?

Yes
No

Anemia due to any cause?

Yes
No

Allergies to Latex? *

Yes
No

Heart Disease?

Yes
No

Cancer (What type)?

Yes
No

High Blood Pressure (Hypertension)?

Yes
No

HIV, Hepatitis B or C? *

Yes
No

Rash, Cuts, Blisters, Open Wounds?

Yes
No

History of fainting?

Yes
No

Any Blood Test / Donated blood recently?

Yes
No

Any Blood Test / Donated blood recently? *

Yes
No

Suffering from Migraines / Headaches?

Yes
No

Suffering from Depression?

Yes
No

Are you on Hormone Therapy?

Yes
No

Are you on contraceptive medications?

Yes
No

Do you have any OBGYN issues?

Yes
No

Metaphysical Issues (Jinn, Seher, Evil Eye)?

Yes
No

Do you smoke?

Yes
No

Do you use drugs?

Yes
No

Check ALL that applies:

Diarrhea
Indigestion
Constipation
Heartburn

Did you discuss with your Primary Physician regarding Wet Cupping and has he/she advised you to avoid it?

Yes
No

primary doc

How did you hear about Hijama *

What is the main reason why you wish to have Hijama done today? *

Health
Something New
Pain Relief

Is there anything in particular you hope to improve with Hijama?

I understand that the medical information recorded in this form is for informational/ therapeutic use only and is strictly confidential. I understand that I must consult with my Medical Doctor if I currently have or develop any of the abovementioned conditions, before I can commence with anybody and energy work. I understand that the practitioner may combine therapies and tailor-make a treatment package for which could include any or all of the treatments: Hijama (Dry/Message/ Wet). • The Practitioner has explained the procedures for all of these treatments. I understand that there will be usage of a surgical blade and blood work during the WET CUPPING procedure. • I give permission to the practitioner to use a small, surgical, incision blade on my body in order to scratch the surface of the skin and draw a small amount of toxic blood according to their professional discretion. I understand that results my not be immediate after each therapy. I take full responsibility for my treatment and have chosen to undertake the Hijama Cupping Therapy. • I Agree to be punctual according to my appointment time, give 24 hours notice before a cancellation and pay a full session’s fee if I do not attend my appointment without prior notice.

CONTRAINDICATIONS: Hijama Cupping Therapy can affect the following list of conditions. All Clients must seek medical advice from their Doctor before commencing treatment sessions. All body and energy work will be practiced at the therapist’s discretion, according to the illness, conditions and stress levels that the client presents with. Diabetes Cancer Cuts/Abrasions Undiagnosed lumps on body Thrombosis/ Embolism Lacerations/ Ulcers Early stages of Labor Recent Injuries/ Surgery Warts/ Skin tags Memory problems Epilepsy Current Fractures Recent Sprains/ Strains Heart Conditions Nerve Dysfunction Ingrown toenails Contagious Diseases Recent Hemorrhage Moles Mood Severe Edema Active Shingles Skin Disease/ Disorders High/ low Blood Pressure Varicose Veins Gout Post- Operation of an Organ transplant Sunburn/ Windburn Bone Fractures Bleeding disorder

Better Health Care is Our Mission

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(763) 213-7574

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info@mnhijama.com

Address: 322 W Lake St, Minneapolis, MN 55408

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