Session Client Medical History - A form to record health / wellbeing.

LINK TO DOWNLOAD

Medical History

Name:			Last STD Test: : ____ _____________ , 20 ___
Do you have a Trichomonas or Yeast Infection?					Yes No
Have you tested Herpes 1 or 2 positive?					Yes No
Have you tested HIV positive?					Yes No
Do you have any current symptoms or historical medical problems involving:
Heart Liver Lungs Kidneys Bladder, Colon or Rectum Dental	Neck or Spinal Cord Bones or Joints Muscles Mucus Membranes Nasal, Oral, Genital Psychological Other: ___________________________
Do you have current symptoms or a medical history of:
Hyperventilation Seizures Dizzy Spells Diabetes	High Blood Pressure Fainting Asthma Other: ___________________________
Do you wear contact lenses or prescription glasses?						Yes No
Do you suffer from any fears or phobias? If so, please describe: ________________________________________________________________ ________________________________________________________________						Yes No
Do you have any surgical implants? If so, please describe: ________________________________________________________________						Yes No
Do you have any piercings of your:
Ear(s) Nose Eyebrow(s) Tongue		Nipple(s) Navel Genitals Other: ______________________________
Are you currently taking any of the following over-the-counter medications:
Aspirin Anti-Inflammatory Antihistamine		Decongestant Expectorant Other: ______________________________
List all prescription medications you currently take:				_______________________________________ _______________________________________ _______________________________________ _______________________________________
Known Allergies including tapes and contraceptives:				_______________________________________ _______________________________________ _______________________________________ _______________________________________
In case of emergency notify: _____________________________________________________________________