4

15.Are

you currently

16. What

Receiving doctor or hospital treatment

Carrying a medical warning card

Pain

Do you suffer from

Allergies to any medicines e.g. penicillin,
latex/rubber, foods
Asthma, Eczema or hay fever
Bronchitis or other chest conditions
Fainting attacks, blackouts or epilepsy
Hear t problems, angina, blood pressure,
Rheumatic Fever
Diabetes
Excessive bleeding problems
Any infectious diseases e.g HIV / Hepatitus

None

are your major complaints?

Head
Neck
Upper Back
Mid Back
Lower Back

Date:
R

Shoulder
Arm
Forearm
Hand

18. After

1.

Name:

2.

Date of Bir th:

3.

Address:

Surname:

Sex: Male / Female:

Age:

Post code:

Buttock
Hip

Home Tel:

Thigh
Leg
Foot

Mobile:

Work:

E-Mail:

Practitioner Notes
17. Treatment

Consultation Sheet

Numbness Tingling

Given:

4.

Marital Status:

5.

Ethnicity:

6.

Weight:

7.

Diet: (please mention details of the main foods you eat regulary, add a typical day):

8.

Work / Studies:

Number of children:
Time in UK (if not born in UK):
Height:

BMI:

Please mark the location of your pain on these figures

Treatment (how the patient felt):

Authorisation

I, the undersigned, do hereby confirm that I am the above-mentioned patient, I have read and understand the
content of this form and also the before and after treatment plan. I give consent for treatment to be carried out
by the practitioner and that my details remain confidential, except when sharing information for data, training
and research. I acknowledge that the information released may include protected and individually identifiable
information about me. I confirm that the information on this form is correct and accurate and no material
information has been omitted. If I become aware that any of the information in this form is incorrect or out of
date, I will inform my Hijama & Alternative Therapy Practitioners immediately. I authorise the release of this form
to my Hijama & Alternative Therapy Practitioners and to The Yorkshire Hijama & Alternative Therapy Clinic &
Associated Health Professionals.
Patients Signature

Print Name

Date

Guardian or Spouse Signature

Print Name

Date

Practitioners Signature

Print Name

Date

Back

Face

Left Side

Right Side

Outside 1 Back R Front L Inside R

2
Current Complaints

9.

Current Complaints

e.

General
Normal
Fatigue
Weakness
Fever
Chills
Weight Change
Night Sweats
Other
Ears

b.

Skin
Normal
Rash
Redness
Itching
Exzema
Hair Changes
Nail Changes
Other

Right Left

f.

Normal
Hearing Trouble
Ringing
Pain
Discharge
Other

i.

Breasts
Normal
Lumps in breast(s)
Redness / Itching
Pain
Dimpling
Discharge
Other

/ Intestines
Normal
Decreased Appetite
Increased Appetite
Abdominal Pain
Vomiting
Diarrhea
Constipation
Other

Questions about menstruation, pregnancy and childbir th

Neurologic
Normal
Headache
Dizziness
Fainting
Convultions
Other

g.

Mouth / Throat
Normal
Sores
Bleeding
Absence of taste
Abnormal Taste
Other

k. Reproductive

Never

Excersie

/ Urination

h.

Heart / Lungs
Normal
Cough
Wheezing
Difficulty Breathing
Swollen Extremeties
Blue extremities
Murmur
Chest Pain
Palpitations
Other

Periods are unchanged

No periods for at least a year

No periods because pregnant or recently gave bir th

Periods have become irregular or changed in frequeny, duration or amount

Having periods because takings hormone

replacement (estrogen) therapy or oral
contraceptive

During the week before your periods star ts, do you have a serious problem with your
mood - like depression, anxiety, irritability, anger or mood swings?

No

If YES: Do these problems go away by the end of your period?

Have you given bir th within the last 6 months?
Have you had a miscarriage within the last 6 months?
Are you having difficulty getting pregnant?

No Yes
To the best of your knowledge are you pregnant
c.

Have you been hospitalized in the past 5 years

d.

Are you currently taking any medication

14. Which

Anti-inflamitory (Asprin, Motrin etc)

Pain Medication/Analgesic

Muscle Relaxants

Bir th Control Pills

Tranquilizers

Other

of the following illnesses have you had?

No previous conditions/illnesses
Ar thritis
Asthma

11.

Currently your pain is aggrevated by

Coughing
Sneezing
Straining at school
Neck Movement
Reaching
Lifting

Ocassionally

Moderatley

Excessively

Bending
Sitting
Standing
Walking
Other

Menstrual cramps or other

problems with your periods

Polio
Rheumatic Fever

Tuberculosis

Pain in your arms, legs or joints

(knees, hips etc)
Constipation, loose bowels,
or diarrheah
Back Pain

Diabetes

Fainting Spells

Multiple Sclerosis

Epilepsy

Kidney Trouble

Scoliosis

Thyroid Trouble

AIDS

Mental/Emotional Difficulty

High Blood Pressure

HIV/ARC

Prostate Trouble

Low Blood Pressure

Shor tness of breath

Sexually Transmited Disease

Hear t Trouble

Nausea, gas or indigestion

Headaches

Feeling your hear t pound or race

Pain or problems during

sexual inercourse

Chest Pain

Scitica

Other

Dizziness
Stomach Pain

Ulcer
Cancer

Sinus Trouble

are your habbits?

Recreational Drugs

Which best describes your menstrual periods?

a.

Vision Trouble
Pain
Discharge
Other

Normal
Heat / Cold Intolerance
Sugar in urine
Goiter
Tremor
Other

Bowel Function
Bladder Function
Ability to maintaining an erection

Alcohol

Right Left

Normal
Inability to hold urine
Painful urination
Frequent Urination
Painful menstruation
Abnormal Vaginal Bleeding
Impotence
Sterility
Other

your symptoms began, have you noticed a change in

Smoking

Eyes
Normal

l. Glandular

Normal
Anxiety
Depression
Memory loss or impairment
Phobias
Mood swings
Other

12. What

d.

b.

Nose
Normal
Pain
Bleeding
Absence of smell
Other

j. Stomach

m. Mental

10. Since

c.

Women

13.

Are you presently suffering (or within the past six months suffered)
a.

Hay Fever
Allergies

Serious Injury
Bone Fracture
Dislocated Joints
Spinal Disc Disease

Yes