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Personal Information
First Name
Last Name
Full Address:
Age
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Email
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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
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Allergies
Are you allergic to any substances or materials?
Do you have a history of skin reactions?
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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?
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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?
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Skin Conditions
Do you have any skin conditions (e.g., eczema, psoriasis) , if so where?
Have you experienced any skin infections recently?
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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
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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?
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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?
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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?
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Hijama Packages
Introductory Wellness Package
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Pain Management Package
Holistic Health Renewal Package
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Home
About Us
Services
1-to-1 coaching
Hijama
Massage
Personalised Nutritional Plans
Privacy Policy
Home
About Us
Services
1-to-1 coaching
Hijama
Massage
Personalised Nutritional Plans
Privacy Policy
Contact Us