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Name : ....................................... Surname....................................Sex : Male / Female : ..............
Date of Birth : ............................................... Age : .........................................................................
Address : .........................................................................................................................................
......................................................................... Pin Code : .............................................................
Home Tel. : ........................................... Mobile : ...........................................................................
Email : ............................................................................................................................................
Marital Status : ................................................... Number of Children : .........................................
Weight : .................................. Height : ............................ BMI : ...................................................
Diet : (Please mention details of main foods you eat regularly, add a typical day) :
.........................................................................................................................................................
Please mark the location of your pain on these figures
Back Face
Left Side Right Side
Outside 1 Back R Front L Inside R

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Current Complaints
9. Are you presently suffering (or within the past six months suffered)
a. General b. Skin c. Neurologic d. Eyes Right Left

Normal Normal Normal Normal
Fatigue Rash Headache
Weakness Redness Dizziness Vision Trouble
Fever Itching Fainting Pain
Chills Exzema Convultions Discharge
Weight Change Hair Changes Other Other
Night Sweats Nail Changes
Other Other
e. Ears Right Left Nose

f. g. Mouth / Throat h. Heart / Lungs
Normal Normal Normal Normal
Pain Sores Cough
Hearing Trouble Bleeding Bleeding Wheezing
Ringing Absence of smell Absence of taste Diff iculty Breathing
Pain Other Abnormal Taste Swollen Extremeties
Discharge Other Blue ex tremities
Other Murmur
Chest Pain
Palpitations
i. Breasts
Other
j. Stomach / Intestines k. Reproductive / Urination
Normal Normal Normal
Lumps in breast(s) Decreased Appetite Inability to hold urine
Redness / Itching Increased Appetite Painful urination
Pain Abdominal Pain Frequent Urination
Dimpling Vomiting Painful menstruation
Discharge Diarrhea Abnormal Vaginal Bleeding
Other Constipation Impotence
Other Sterility
Other
m. Mental l. Glandular
Normal Normal
Anxiety Heat / Cold Intolerance
Depression Sugar in urine
Memory loss or impairment Goiter
Phobias Tremor
Mood swings Other
Other
10.Since your symptoms began, have you noticed a change in 11.Currently your pain is aggrevated by
Bowel Function Coughing Bending

Sneezing Sitting
Bladder Function
Straining at school Standing
Ability to maintaining an erection
Neck Movement Walking
Reaching Other
Lifting
12.What are your habbits?
Never Ocassionally Moderatley Excessively
Smoking
Alcohol
Recreational Drugs
Excersie

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Current Complaints
13.Women
Questions about menstruation, pregnancy and childbir th

a. Which best describes your menstrual periods?
Periods are unchanged No periods for at leas t a year
No periods because pregnant or recently gave birth Having periods because takings hormone
Periods have become irregular or changed in frequeny, duration or amount replacement (estrogen) therapy or oral
contraceptive
b. During the week before your periods star ts, do you have a serious problem with your No Yes
mood - like depression, anxiety, irritability, anger or mood swings?
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 diff iculty 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
Anti-inflamitory (Asprin, Motrin etc) Pain Medication/Analgesic

Muscle Relaxants Birth Control Pills
Tranquilizers Other
14.Which of the following illnesses have you had?

No previous conditions/illnesses
Arthritis Menstrual cramps or other Polio
Asthma problems with your periods Rheumatic Fever
Sinus Trouble Pain in your arms, legs or joints Serious Injury
(knees, hips etc)
Hay Fever Bone Fracture
Constipation, loose bowels,
Allergies or diarrheah Dislocated Joints
Tuberculosis Back Pain Spinal Disc Disease
Diabetes Fainting Spells Multiple Sclerosis
Epilepsy Kidney Trouble Scoliosis
Thyroid Trouble AIDS Mental/Emotional Difficulty
High Blood Pressure HIV/ARC Pros tate Trouble
Low Blood Pressure Shor tness of breath Sexually Transmited Disease
Heart Trouble Nausea, gas or indigestion Pain or problems during

Feeling your hear t pound or race sexual inercourse
Headaches
Scitica Other
Chest Pain
Dizziness Ulcer
Stomach Pain Cancer

45
Are you currently What are your major complaints ? None
Receiving doctor or hospital treatment Pain Numbness Tingling
Head
Carrying a Medical Warning Card
Neck
Upper Back
Do you suffer from Mid Back
Allergies to any medicines e.g. penicillin Lower Back
R L R L R L
latex/rubber, foods Shoulder
Asthma, Eczema or hay fever Arm
Bronchitis or other chest conditions Forearm
Hand
Fainting attacks, blackout or epilepsy
Heart Problems, Angina, Blood Pressure, Buttock
Rheumatic Fever Hip
Diabetes
Thigh
Excessive Bleeding Problems Leg
Any infectious disease eg. HIV/Hepatitus Foot
Practitioner Notes :
Treatment Given :
After 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

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