Hijama Maloomat

Contact us at : 0091-9860515918
Mail us at : arifahemad72@gmail.com
New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918

Contact us at : 0091-9860515918

Contact us at : 0091-9860515918

Contact us at : 0091-9860515918

Contact us at : 0091-9860515918

Contact us at : 0091-9860515918

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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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43
Current Complaints
9.
Are you presently suffering (or within the past six months suffered)
a.
General Normal Fatigue Weakness Fever Chills Weight Change Night Sweats Other Ears Normal Right Left
b.
Skin Normal Rash Redness Itching Exzema Hair Changes Nail Changes Other
f.
c.
Neurologic Normal Headache Dizziness Fainting Convultions Other
d.
Eyes Normal Vision Trouble Pain Discharge Other
Right Left
e.
Hearing T rouble Ringing Pain Discharge Other
i. Breasts
Normal Lumps in breast(s) Redness / Itching Pain Dimpling Discharge Other
Nose h. Heart / Lungs g. Mouth / Throat Normal Normal Normal Pain Cough Sores Wheezing Bleeding Bleeding Diff iculty Breathing Absence of smell Absence of taste Swollen Extremeties Other Abnormal Taste Blue ex tremities Other Murmur Chest Pain Palpitations Other j. Stomach / Intestines k. Reproductive / Urination Normal Normal Decreased Appetite Inability to hold urine Increased Appetite Painful urination Abdominal Pain Frequent Urination Vomiting Painful menstruation Diarrhea Abnormal Vaginal Bleeding Constipation Impotence Other Sterility Other
l. Glandular
m. Mental
Normal Anxiety Depression Memory loss or impairment Phobias Mood swings Other
10.Since
Normal Heat / Cold Intolerance Sugar in urine Goiter T remor Other
your symptoms began, have you noticed a change in 11.Currently your pain is aggrevated by Coughing Sneezing Straining at school Neck Movement Reaching Lifting Excessively Bending Sitting Standing Walking Other
Bowel Function Bladder Function Ability to maintaining an erection
12.What
are your habbits? Never Ocassionally Moderatley
Smoking Alcohol Recreational Drugs Excersie
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44
Current Complaints
13.Women
Questions about menstruation, pregnancy and childbir th

a.
Which best describes your menstrual periods?

Periods are unchanged No periods because pregnant or recently gave birth Periods have become irregular or changed in frequeny, duration or amount No periods for at leas t a year Having periods because takings hormone replacement (estrogen) therapy or oral contraceptive
b.
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? 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
Y es
No To the best of your knowledge are you pregnant

c. d.
Yes
Have you been hospitalized in the past 5 years Are you currently taking any medication
Anti-inflamitory (Asprin, Motrin etc) Muscle Relaxants T ranquilizers Pain Medication/Analgesic Birth Control Pills Other
14.Which
of the following illnesses have you had?

Polio Rheumatic Fever Serious Injury Bone Fracture Dislocated Joints Spinal Disc Disease Multiple Sclerosis Scoliosis Mental/Emotional Difficulty Pros tate T rouble Sexually T ransmited Disease
No previous conditions/illnesses Arthritis Asthma Sinus T rouble Hay Fever Allergies T uberculosis Diabetes Epilepsy Thyroid T rouble High Blood Pressure Low Blood Pressure Heart T rouble
Menstrual cramps or other problems with your periods Pain in your arms, legs or joints (knees, hips etc) Constipation, loose bowels, or diarrheah Back Pain Fainting Spells
Kidney T rouble AIDS HIV/ARC
Shor tness of breath Nausea, gas or indigestion Feeling your hear t pound or race
Scitica Ulcer Cancer
Headaches Chest Pain Dizziness Stomach Pain
Pain or problems during sexual inercourse Other
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45
Are you currently Receiving doctor or hospital treatment Carrying a Medical Warning Card 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, blackout or epilepsy Heart Problems, Angina, Blood Pressure, Rheumatic Fever Diabetes Excessive Bleeding Problems Any infectious disease eg. HIV/Hepatitus
What are your major complaints ? None Pain Numbness Tingling Head Neck Upper Back Mid Back Lower Back R L R L R L Shoulder Arm Forearm Hand Buttock Hip Thigh Leg 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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Contact us at : 0091-9860515918

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

Outside 1 Back R Front L Inside R

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

Neurologic Normal Headache Dizziness Fainting Convultions Other

Eyes Normal Vision Trouble Pain Discharge Other

Hearing T rouble Ringing Pain Discharge Other

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

Normal Heat / Cold Intolerance Sugar in urine Goiter T remor Other

Bowel Function Bladder Function Ability to maintaining an erection

are your habbits? Never Ocassionally Moderatley

Smoking Alcohol Recreational Drugs Excersie

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

Questions about menstruation, pregnancy and childbir th

Which best describes your menstrual periods?

No To the best of your knowledge are you pregnant

of the following illnesses have you had?

Headaches Chest Pain Dizziness Stomach Pain

Pain or problems during sexual inercourse Other

New Ellora Enterprises Wholesale Dealer : Cupping (Hijama Cups)

Practitioner Notes : Treatment Given :

After Treatment (How the Patient felt)

Guardian or Spouse Signature