PH: 0422 211 104 HOMEABOUTSERVICES NEUROBELIEF SYSTEMCELLULAR HEALTHENERGYPHYSICAL TESTIMONIALSCONTACT Confidential Health & Medical Intake Form Name: *DOB: *MOB: *Address *Email *Emergency (Name and MOB): *Reason/s for seeking treatment: *Please enter your health history include any traumas, scars, tattoo, piercing, dental work (fillings, root canals) or birthmarks: *List all illnesses, injuries, and health concerns you have now or have had in the past ten years (e.g. diabetes, arthritis, broken bones, pregnancy). *List all medications and pain relief taken this week. *Do you currently or frequently have any of the following (Yes or No)?Lower back pain: *YesNoNeck pain: *YesNo Headaches/Migraines: *YesNoDo you have any other muscular, skeletal, or connective tissue conditions? *Are you currently experiencing any of the following (Yes or No)? If yes, please explain:Pain/tenderness: *YesNoNumbness or tingling: *YesNo Headaches/Migraines: *YesNoSwelling: *YesNoAllergies: *YesNoExplain here... *I have provided all my known medical condition. I acknowledge that the therapy is not a substitute for medical diagnosis or treatment. I consent the receive treatment.SUBMIT
