Name

Sex

Male

Female

Tel/Cell2

Date of birth

Postal code

Address

Occupation

HAVE YOU EVER SUFFERED A MAJOR INJURY OR DISEASE

YES

IF YES, PLEASE SPECIFY

ARE YOU CURRENTLY UNDER A DOCTOR'S CARE?

YES

IF YES, PLEASE SPECIFY

DO YOU SUFFER FROM ALLERGIES?

YES

IF YES, PLEASE SPECIFY

ARE YOU TAKING ANY MEDICATION?

YES

IF YES, PLEASE SPECIFY

DO YOU HAVE A PACEMAKER?

YES

DO YOU WEAR CONTACT LENSES?

YES

BLOOD PRESSURE

HIGH

LOW

NORMAL

HOW OFTEN DO YOU EXERCISE?

NEVER

DAILY

REGULARLY

HOW OFTEN DO YOU SMOKE?

NEVER

DAILY

SOCIALLY

HOW OFTEN DO YOU DRINK?

NEVER

DAILY

SOCIALLY

EATING HABITS

THREE MEALS A DAY

TWO MEALS A DAY

ONE MEAL A DAY

HAVE YOU EVER HAD A MASSAGE AND ACUPUNCTURE TREATMENT?

YES

[FOR WOMAN ONLY]PERIOD CYCLE

REGULAR

IRREGULAR

[FOR WOMAN ONLY]ARE YOU PREGNANT?

YES

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