Ionic Detox Health Record

Date:				
Name:							    Date of Birth:				
Address:					 City & Province:					  
Postal Code:		      Email Address					
Phone (Res) 			  Phone  (Bus.)		 		 
Occupation: 				Doctor:			 Doctor Tel.:			

1.	Are you in good health? 
Yes	  No	  
2.	Are you undergoing other therapies?
Yes	  No		
List:				
3.	What else are you doing for your health?											
4.	What are your goals/expectations for this session?										
5.	When did you last visit your doctor?							
Reason:					
6.	List past surgeries and time of surgery:												
7.	List past injuries and time of injury:												
8.	Are you taking medications? (Please include any vitamins or dietary supplements.)	
	Yes	 No	
Reason for taking:									
9.	Do you sleep well?  Yes	 No	
Explain:					
10.	Do you suffer from anxiety or worry? 	
Yes	 No	
Explain:					
11.	Is your blood pressure:
Normal	       High            Low             Stable	       
Erratic   

12.	Are you pregnant?	Yes	 No	
If yes, which trimester? 1       2       3	
13.	Have you had other pregnancies?
Yes	  No	
14.	Do you have allergies/sinus conditions? 
 Yes	 No	
15.	Do you have varicose veins?
Yes	 No	
16.	Do you wear prosthesis (e.g. glasses, contacts, glass eye, artificial joints/limbs, metal plates, pins or wires, dentures, hearing aid?) 
	Yes	  No	
If yes please list:									
17.	Is there anything else about your health you wish to discuss?									
18.	Are you presently experiencing any of the following?
Sunburn	       Inflammation	     Pain	  Headache	        Skin rash       Cold/flu	    Cuts, bruises, burns	         Decreased range of motion	   other	 
19.	Please indicate your consumption of the following: 
None	Light	Moderate   Heavy	
Salt		       	         	        	        	
Sugar	        	        	        	        	
Caffeine	        	        	        	        	
Tobacco	        	        	        	        	
Alcohol	        	        	        	        	
Water	        	        	        	             	  
Exercise	        	         	        	        	

Do you have problems with any of the following?

ENDOCRINE SYSTEM:		Y      N
(E.g. diabetes, hypoglycemia, menopausal problems, hypothyroid, hyperthyroidism)	
Specify:					

URINARY SYSTEM:		Y     N
(E.g. kidney disease, urinary problems)	  
Specify:					

CARDIOVASCULAR:		Y      N
(E.g. high/low blood pressure, heart disease, phlebitis, varicose veins, circulation problems, anemia, etc.)
Specify:					

IMMUNE & LYMPHATIC:	  	Y     N
(E.g. arthritis, chronic fatigue, environmental illness, HIV/ AIDS, allergies, etc.)
Specify:					

MUSCULOSKELETAL: 		Y     N
(E.g. osteoporosis, fibromyalgia, bursitis, gout, back pain, scoliosis, foot, arm, or hand problems)
Specify:					

RESPIROTORY:			Y     N
(E.g. asthma, emphysema, etc.)
Specify:					

NERVOUS:			Y     N
(E.g. vision, hearing loss/problems, loss of sensation, nerve pain/damage, mental or emotional problems, MS)
Specify:					

REPRODUCTIVE:			Y     N
(E.g. PMS, dysmenorrhoea, endometriosis, prostate problems, etc,)
Specify:					

DIGESTIVE:			Y      N
(E.g. prolonged constipation, diarrhea, Crohn’s disease, colitis, diverticulitis, ulcer, etc.)
Specify:					

INGUMENTARY:			Y      N
(E.g. Psoriasis, eczema, warts, etc.)
Specify:					

OTHER:
Tuberculosis:		Y	N
Hepatitis:			Y	N
Herpes:  			Y	N
Cancer:			Y	N

CONSENT TO RECEIVE TREATMENT

I, the undersigned, consent to ionic detox treatment and understand that sessions are for the purpose of stress reduction and relaxation.

I may stop the session at any time, either during the assessment or the treatment.

Clinicians and ionic detox do not diagnose, prescribe medication for medical or psychological conditions, or treat for specific conditions.

							
                    Signature			          Date