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Health form (for Tui Na, Tong Ren, Cupping, Gua Sha, Chi Kung / Qi Gong)

For any sessions involving a hands-on or quantum healing modality, such as Tui Na, Tong Ren, Cupping, Gua Sha, Chi Kung / Qi Gong, please complete this form.

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Question 1 of 10

List health concerns in order of importance. Describe onset, symptoms, where and when did it occur, and any related psychological/mental/emotional/spiritual considerations.

Question 2 of 10

Do you use:

(Select all that apply)
A

Herbs

B

Homeopathics

C

Alcohol

D

Tobacco

E

None of the above

Question 3 of 10

Have you experienced any of the following before?

(Select all that apply)
A

Acupuncture

B

Tui Na - Acupressure

C

Cupping

D

Quantum/Remote healing method

E

Gua Sha

F

Tong Ren

G

None of the above

Question 4 of 10

Are you seeing a health care professional for this issue?

(Select all that apply)
A

Physician

B

Chiropractor

C

Physical Therapist

D

Psychiatrist

E

Other

F

New Choice

G

None of the above

Question 5 of 10

Identify any significant health history - including surgery, past accidents/injuries, family history, and diagnosis.

Question 6 of 10

Identify any allergies - medication, food, environmental:

Question 7 of 10

Names of all drugs and medicines you are now taking:

Question 8 of 10

List all minerals, vitamins, herbal, homeopathic supplements you are taking:

Question 9 of 10

Identify the conditions that apply:

(Select all that apply)
A

Seizures

B

Dizziness

C

Vertigo

D

Muscle spasms or tremors

E

Slurred speech

F

Speech problems

G

Muscle weakness

H

Asthma, wheezing

I

Cough

J

Coughing up blood or sputum

K

Rapid breathing

L

Shortness of breath

M

Repeated nose or chest colds

N

Ankle swelling

O

Rapid/irregular pulse

P

High cholesterol

Q

Chest pain

R

Breast tenderness

S

Low cholesterol

T

Stroke

U

Low blood pressure

V

High blood pressure

W

Facial pain

X

Headache

Y

Neck pain or stiffness

Z

Neck pain or stiffness

AA

Frequent sore throat

AB

Frequent sore throat

AC

Blurred or double vision

AD

See spots or shadows

AE

Hearing loss

AF

Ear ringing

AG

Disturbances in smell

AH

Chronic ear infections

AI

Sore tongue

AJ

Dry mouth

AK

Abdominal (stomach/belly) pain

AL

Anal itching

AM

Nausea or vomiting

AN

Painful bowel movements

AO

Liquid bowel movements

AP

Infrequent bowel movements

AQ

Loss of bowel movement

AR

Frequent belching or gas

AS

Vomiting blood

AT

Rectal bleeding (red or black blood)

AU

Jaundice (yellowing of skin)

AV

Arthritis

AW

Back pain or stiffness

AX

Back pain or stiffness

AY

Bone pain

AZ

Joint pain or stiffness

BA

Leg pain

BB

Muscle cramps or pain

BC

Dry hair or skin

BD

Itchy skin or scalp

BE

Easy bruising

BF

Hair loss

BG

Increased perspiration

BH

Sun sensitivity

BI

Itchy privates or genitals

BJ

Painful urination

BK

Excessive urination

BL

Decreased sexual desire

BM

Tonsillectomy

BN

Adenoidectomy

BO

Myringotomy (ear tubes)

BP

Hernia repair

BQ

Appendectomy

BR

Pneumonia

BS

Hypothyroidism

BT

Hyperthyroidism

BU

Chronic Fatigue Syndrome

BV

Fibromyalgia

BW

Encephalitis

BX

Meningitis

BY

Lyme disease

BZ

Lupus

CA

Epstein - Barr virus

CB

Fevers over 105degF

CC

Autoimmune Disorder

CD

Being overweight

CE

Weight loss

CF

Sensitive to hot or cold

CG

Cold or hot spells

CH

Fatigue

CI

Lowered resistance to infection

CJ

Flu-like or vague sick feeling

CK

Night sweats

CL

Daytime sweating

CM

Excessive thirst

CN

None of the above

Question 10 of 10

Consent Form

Confidentiality

All information that we discuss is completely confidential and will never be shared by Agnes Chau LLC with anyone other than you, unless you authorize Agnes Chau LLC and its members to do so directly, and except where required by law.

Liability & Release

Agnes Chau LLC will take reasonable precautions to help prevent risks, injuries, or exposures from occurring; however, Participant also understands and acknowledges that there are no warranties, assurances, or guarantees, express or implied, regarding the occurrence of any such risk, injury, or exposure to Participant while participating in any activity sponsored or conducted by Agnes Chau LLC. Participant’s decision to participate in any of Agnes Chau LLC's sessions, programs, courses, or events, is knowing and purely voluntary, and Participant, if Participant chooses to participate in an event or activity sponsored or conducted by Agnes Chau LLC, hereby knowingly and voluntarily assumes all risks of participation and waives all claims relating to risk, injury or exposure, as more fully set forth below.

Participant, individually or on behalf of his/her heirs and assigns, hereby fully releases and forever discharges Agnes Chau LLC, as well as each of its respective administrators, representatives, assigns, beneficiaries, agents, affiliates, employees, servants, officers, members, partners, predecessors, successors, insurers, attorneys, and any other related person or entity (collectively “Released Parties”), from all past, present, or future actions, causes of action, claims, controversies, costs, covenants, damages, demands, expenses, liabilities, losses, and suits for damages of whatsoever kind and nature, under any theory of recovery at law, by statute, in equity or otherwise, whether now known or unknown, and suspected or unsuspected, which have existed or may have existed, or which do exist, or which hereafter can, shall, or may exist, including, but not limited to, tort or contractual claims, economic or non-economic damages, compensatory or punitive damages, property damage, loss of use, investigatory costs, attorneys’ fees, expert costs and expenses, interest, or any other damages, whether caused or contributed to, in whole or in part, by the negligent or reckless conduct of the Released Parties, which in any way arise out of or relate to Participant’s knowing and voluntary participation in the services, programs, courses, events of Agnes Chau LLC.

Cancellations & Rescheduling

Cancellations and rescheduling must be done at least 24 hours prior to the session in order to get a credit. It is important for participants to attend appointments at the scheduled time. Missed or canceled appointments with less than 24 hours notice will not be refunded. 

Waiver & Release

By entering the name and date below, Participant warrants and represents that he/she has carefully read and understands this Release and that he/she has freely and voluntarily executed this Release without any coercion or duress. Participant has relied upon his/her own knowledge or, prior to signing, has consulted with or had an opportunity to consult with legal counsel of his/her choice concerning the legal consequences of signing this Release. Participant warrants and represents that he/she has not relied upon any advice, statement, or representation pertaining to this Release by Agnes Chau LLC in executing this Release. 

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