Hijama New Client Form | Moderni Spine

Sex

Male

Female

How did you find us?

I Consent to the following communication methods from Moderni Spine pllc: (check all that apply)

PHONE CALL (REQUIRED)

EMAIL

PHONE TEXT

MAIL

CURRENT MEDICATONS

I am taking a BLOOD THINNING medication (i.e. Eliquis, Coumadin, Warfarin, Pradaxa)

I am on a ANTIBIOTIC for a CURRENT INFECTION

I am taking a long-term ANTIBIOTIC for a chronic condition

NONE of the above

Medical History

GENERAL SYMPTOMS

RESPIRATORY

ENDOCRINE

EYE/EAR/NOSE/THROAT

MUSCLE AND BONE

URINARY/GYN

PSYCHOLOGICAL

Depression

Anxiety

Manic episodes

SKIN

Skin rash

Itching

Lumps or masses

Abnormal moles

CARDIOVASCULAR

GASTROINTESTINAL

NEUROLOGICAL

Reason seeking Hijama therapy (select all that apply)

Hijama New Client Intake Form