Confidential Health Information Form

MZ Therapy Confidential Health Information Form
MM slash DD slash YYYY
Your Name
MM slash DD slash YYYY
Your Address
Email Address
Osteoarthritis? Rheumatoid Arthritis? Spinal Fractures? Ruptured discs? Spinal Fusion or Discectomy? Scoliosis? Bone Fracture within the last 2 years? Tendonitis? Osteopenia? Or Osteoporosis?
High/low Blood Pressure Previous Heart Attacks/ Strokes/ Arrhythmia/ Heart valve complications
Asthma? COPD? Shortness of breath - and or with exercise? Difficulty on inhale or exhale? Pain with breathing?
Recent changes in digestion? Slow digestion? Heart burn or acid reflux? IBS? Constipation or Diarrhea? Bloating, Nausea, Stomach pain Or any other?
Absent or painful menstruation? Menopause? And if so do you take HRT? Incontinence?
Please note Symptoms, Diagnosis, Treatment and date of:
Frequent illness? Thyroid issues? Fatigue or low energy? Allergies or food sensitivities?
Shakes? Numbness? Brain fog? Headaches? Tinnitus?
Difficulty falling asleep? Frequent waking during the night? Waking early in the morning? Not feeling rested in the morning?
Joy, depression, anxiety, anger or other
Are your mealtimes - regular? Erratic? Late in the evening?
Do you drink Alcohol?
Do you smoke?
Do you drink caffeine
Mother? Father? Grandparents? Sibling?