CONFIDENTIAL HEALTH INFORMATION FORM

Confidential Health Information Form

MZ Therapy Confidential Health Information Form

Today's Date

Your Name

Prefix First Last

Date of Birth

Your Address

Address Line 1 Address Line 2 City County Post Code

Telephone

Email Address

Enter Email Confirm Email

Gender

Relationship Status

Number and Ages of Children

Occupation

Describe reasons for interest in Yoga Therapy/Rolfing

Describe previous yoga experience, sporting or recreational activities enjoyed

Goals desired with Yoga Therapy/ Rolfing

Do you have any numbness, pain, limitations of movement in: Feet Ankles Knees Sacrum/ hips Lower back Upper back Shoulders Arms - wrists - hands Neck

SURGERIES and date of:

ACCIDENTS/ INJURIES and date of:

MUSCULO-SKELETAL Issues?

Osteoarthritis? Rheumatoid Arthritis? Spinal Fractures? Ruptured discs? Spinal Fusion or Discectomy? Scoliosis? Bone Fracture within the last 2 years? Tendonitis? Osteopenia? Or Osteoporosis?

CARDIOVASCULAR issues?

High/low Blood Pressure Previous Heart Attacks/ Strokes/ Arrhythmia/ Heart valve complications

RESPIRATORY issues?

Asthma? COPD? Shortness of breath - and or with exercise? Difficulty on inhale or exhale? Pain with breathing?

DIGESTIVE DISORDERS?

Recent changes in digestion? Slow digestion? Heart burn or acid reflux? IBS? Constipation or Diarrhea? Bloating, Nausea, Stomach pain Or any other?

WOMEN’S HEALTH ISSUES?

Absent or painful menstruation? Menopause? And if so do you take HRT? Incontinence?

Do you have any other Health issues like - Cancer? Diabetes? Epilepsy? Fibromyalgia? Headaches? Migraines?

Please note Symptoms, Diagnosis, Treatment and date of:

ENDOCRINE OR IMMUNE system issues?

Frequent illness? Thyroid issues? Fatigue or low energy? Allergies or food sensitivities?

NERVOUS SYSTEM issues?

Shakes? Numbness? Brain fog? Headaches? Tinnitus?

How is your sleep?

Difficulty falling asleep? Frequent waking during the night? Waking early in the morning? Not feeling rested in the morning?

Are you currently taking any medication? Herbal supplements? Please list with reasons.

What is your prevailing mood, emotional state?

Joy, depression, anxiety, anger or other

Typical diet?

Are your mealtimes - regular? Erratic? Late in the evening?

Do you drink Alcohol?

Yes

Number of units per week?

Do you smoke?

Yes

Number per day

Do you drink caffeine

Yes

Number of cups per day

Please list any chronic family health conditions:

Mother? Father? Grandparents? Sibling?