• Ele King Therapy Room Client form

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you on any medication? If so please let us know what medication

  • Have you had any operations in the last 6 months? If so please state what

  • Have you had any major illnesses?

  • Are you pregnant or breastfeeding?
  • Are you Currently seeing any other health practitioners? If yes please state what for

  • Have you had any scans for current injuries in the last 6 months? If yes please state what for

  • Are you immunocompromised?
  • Are you taking blood thinners?
  • Do you have a pacemaker or electrical implants? If yes please state what implant

  • Have you ever fainted or experienced seizures?
  • Do you suffer from any of the following?
  • Have you been diagnosed with Cancer? if so please give details

  • Are you taking antibiotics for an infection? if so please give details

  • Do you have?
  • Do you suffer from metal allergies?
  • Do you suffer from back problems?
  • Do you suffer from any of the following?
  • Do you suffer with Psychiatric or mental illness
  • Do you suffer with any allergies? if so please give details

  • Are you diabetic or do you suffer from impaired wound healing?
  • Do you have Hepatitis B, C, HIV or any other infectious disease? if yes please give details

  • Dry Needling / Massage cupping / Dry Cupping

    If the therapist feels it necessary during the treatment, are you happy to have some or all of the above done? if you do not know what is involved please ask for an explanation of each and only sign once this has been explained. 


  • Hijama (wet cupping)
    ONLY ANSWER IF THIS IS THE TREATMENT YOU ARE BOOKED IN FOR

  • Are you booking in for a Hijama treatment?
  • Are you severely anaemic?

  • (if you are mildly anaemic please note you must confirm to your therapist that you are taking your prescribed tablets for 2 weeks prior to treatment

  • Do you understand that Hijama will leave incision marks on your body?
  • Do you understand that there will be discolouration where the cups are placed?
  • Do you understand you may feel worse for a few days following treatment and an increase in pain as your body adjusts?

  • Declaration:

    To the best of my knowledge I confirm that all the answers I have given are correct and truthful. That my mental and physical health and fitness is good that if there is any change in my condition between treatments `i will tell the therapist. I confirm I am happy for the therapist to carry out the treatment on me:

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  • Should be Empty: