Cupping Intake Forms Please fill out the following requested information as thoroughly as possible. It is best to complete this form on a desktop computer. In general, this process takes 3-5 minutes. About You Full Name(required) Date of Birth(required) Age(required) Address(required) Phone(required) Email(required) Occupation Referred By Have you ever had cupping before? Yes No What is the main reason for your visit?(required) List any past surgeries/hospitalizations List any current and/or past infectious diseases you've been diagnosed with If applicable, how long ago were you diagnosed with the infectious disease(s) listed above? List anything (medications, food, oils, scents, etc.) that have caused you to have an allergic reaction and how it manifests (i.e rash, swelling, sneezing, etc) Emergency Contact Name of emergency contact(required) Emergency contact phone number(required) Relationship to patient Current Medications List the name(s) of current medication(s) Reason(s) for taking medication(s) in same order as listed above General (check mark any conditions you've experienced in the last 3 months) Easy Bleeding Easy Bruising Chills/ Fever Fatigue Headaches Poor balance Dizziness or fainting Eczema Rash/hives Psoriasis New or changing spots on the skin Skin Ulcers Muscular Skeletal (check all that apply) Back pain Disc fusions Neck pain Muscle cramping/soreness/weakness/spasms Scoliosis Shoulder pain Arthritis Other Describe the pain or discomfort Electronic Signature I certify that the information provided above is current and accurate to the best of my knowledge(required) Date(required) Please view the following consent forms. Cancellation PolicyDownload Disclosure-Statement-AshleighDownload Disclosure-Statement-MichelleDownload HIPAA-PolicyDownload Submit Δ Like this:Like Loading...
