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Personal Information

First Name

Last Name

Full Address:

Age

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Email

Medical History

Do you have any existing medical conditions? If yes, please specify

Are you currently taking any medications? If yes, please list them

Have you had any recent surgeries or medical procedures?

Do you have any medical conditions that affect your blood clotting or are you taking any blood thinners?

Are you currently experiencing any pain, discomfort, or specific health issues? If yes, please provide details

Allergies

Are you allergic to any substances or materials?

Do you have a history of skin reactions?

Cupping Experience

Have you received cupping therapy before? If yes, please share your experience

Is there a specific reason for seeking cupping therapy at this time?

How many days per week do you typically engage in physical activity?

Pregnancy and Women's Health

Are you currently pregnant or trying to conceive?

Are you breastfeeding?

Do you have any gynaecological conditions we should be aware of?

Skin Conditions

Do you have any skin conditions (e.g., eczema, psoriasis) , if so where?

Have you experienced any skin infections recently?

Mental Health

On a scale of 1-10, how would you rate your current level of stress?

Are you experiencing any physical symptoms related to stress (e.g., headaches, muscle tension, sleep disturbances)?

Do you notice any changes in your mood or emotions (e.g., irritability, anxiety, sadness)?

Have you tried any stress management techniques in the past? If so, please share your experiences

Lifestyle Factors

How would you describe your current lifestyle, including diet, exercise, and sleep patterns?

Are there any significant life changes or transitions contributing to your stress?

Expectations

What are your expectations or goals for this cupping session?

Is there anything specific you would like the therapist to focus on or avoid?

Emergency Contact Information

I understand that cupping therapy is not a substitute for medical care, and I will consult with my healthcare provider for any serious health concerns

Yes

No

Is there anything else you would like to share with the practitioner regarding your health or preferences for the cupping treatment?

Payment Info

Hijama Packages

Introductory Wellness Package

Stress Relief and Relaxation Package

Pain Management Package

Holistic Health Renewal Package

Customized Detoxification Package

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Phone/Mobile

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