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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
-
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
-
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
-
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
-
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
-
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora EnterprisesWholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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Name : ....................................... Surname....................................Sex : Male / Female : ..............
Date of Birth : ............................................... Age : .........................................................................
Address : .........................................................................................................................................
......................................................................... Pin Code : .............................................................
Home Tel. : ........................................... Mobile : ...........................................................................
Email : ............................................................................................................................................
Marital Status : ................................................... Number of Children : .........................................
Weight : .................................. Height : ............................ BMI : ...................................................
Diet : (Please mention details of main foods you eat regularly, add a typical day) :
Please mark the location of your pain on these figures
.........................................................................................................................................................
Back Face
Left Side Right Side
Outside 1 Back R Front L Inside R
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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Normal
FatigueWeakness
Fever
Chills
Weight ChangeNight Sweats
Other
h. Heart / Lungs
Normal
CoughWheezing
Diff iculty BreathingSwollen Ex tremeties
Blue extremities
Murmur
Chest PainPalpitations
Otheri.Breasts
Normal
Lumps in breast(s)
Redness / Itching
Pain
Dimpling
DischargeOther
j.Stomach / Intestines
Normal
Decreased AppetiteIncreased Appetite
Abdominal PainVomitingDiarrhea
ConstipationOther
k.Reproductive / Urination
Normal
Inability to hold urine
Painful urinationFrequent Urination
Painful menstruation
Abnormal Vaginal BleedingImpotence
SterilityOther
l.Glandular
Normal
Heat / Cold IntoleranceSugar in urineGoiter
TremorOther
m.Mental
Normal
AnxietyDepression
Memory loss or impairment
PhobiasMood swings
Other
b. Skin
NormalRash
RednessItching
Exzema
Hair ChangesNail ChangesOther
c. Neurologic
Normal
HeadacheDizziness
Fainting
Convultions
Other
d. Eyes
Normal
Vision TroublePain
Discharge
Other
Right Left
e. Ears
Normal
Hear ing TroubleRinging
Pain
DischargeOther
Right Left f. Nose
Normal
Pain
Bleeding
Absence of smell
Other
g. Mouth / Throat
Normal
SoresBleeding
Absence of taste
Abnormal Taste
Other
12.What are your habbits?
Smoking
Alcohol
Recreational Drugs
Excersie
Never Ocassionally Moderatley Excessively
11.Currently your pain is aggrevated by
Coughing
Sneezing
Straining at school
Neck Movement
Reaching
Lifting
Bending
Sitting
Standing
Walking
Other
10.Since your symptoms began, have you noticed a change in
Bowel Function
Bladder Function
Ability to maintaining an erection
Current Complaints
you presently suffering (or within the past six months suffered)
a. General
9.Are
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
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New Ellora Enterprises
Wholesale Dealer : Cupping (Hijama Cups)
Visit us at : www.tibbenabavi.com, www.hijamacups.com
Contact us at : 0091-9860515918 Mail us at : [email protected]
Current Complaints
To the best of your knowledge are you pregnant
Anti-inflamitory (Aspr in, Motrin etc)
Muscle Relaxants
Tranquilizers
Pain Medication/Analgesic
Birth Control Pills
c.
d.
13.
Have you been hospitalized in the past 5 years
Are you currently taking any medication
Women
No Yes
No Yes
Questions about menstruation, pregnancy and childbirth
Which best describes your menstrual periods?
During the week before your periods starts, do you have a serious problem with your
a.
b.
mood - like depression, anxiety, irr itability, anger or mood swings?
If YES: Do these problems go away by the end of your period?
Have you given birth within the last 6 months?
Have you had a miscarriage within the last 6 months?
Are you having diff iculty getting pregnant?
Periods are unchanged
No periods because pregnant or recently gave birth
Periods have become irregular or changed in frequeny, duration or amount
No periods for at least a year
Having periods because takings hormone
replacement (estrogen) therapy or oral
contraceptive
Feeling your hear t pound or race
Constipation, loose bowels,
or diarrheah
Which of the following illnesses have you had?14.
No previous conditions/illnesses
Arthritis
Asthma
Sinus Trouble
Hay Fever
Allergies
Tuberculosis
Diabetes
Epilepsy
Thyroid Trouble
High Blood Pressure
Low Blood Pressure
Hear t Trouble
Polio
Rheumatic Fever
Serious Injury
Bone Fracture
Dislocated Joints
Spinal Disc Disease
Multiple Sclerosis
Scoliosis
Mental/Emotional Difficulty
Pros tate Trouble
Pain in your arms, legs or joints
(knees, hips etc)
Menstrual cramps or otherproblems with your periods
Pain or problems during
sexual inercourse
Stomach Pain
Sexually Transmited Disease
Headaches
Chest Pain
Dizziness
Nausea, gas or indigestion
Back Pain
Fainting Spells
Shortness of breath
Other
Kidney Trouble
AIDS
HIV/ARC
Scitica
Ulcer
Cancer
Other
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What are your major complaints ? None Pain Numbness TinglingHeadNeckUpper BackMid BackLower Back R L R L R LShoulder
ArmForearmHand
ButtockHip
ThighLegFoot
Are you currently
Do you suffer from
Receiving doctor or hospital treatment
Carrying a Medical Warning Card
Allergies to any medicines e.g. penicillin
latex/rubber, foods
Asthma, Eczema or hay feverBronchitis or other chest conditions
Fainting attacks, blackout or epilepsy
Heart Problems, Angina, Blood Pressure,
Rheumatic Fever
Diabetes
Excessive Bleeding Problems
Any infectious disease eg. HIV/Hepatitus
Authori sat ionI, the undersigned, do hereby confirm that I am the above-mentioned patient, I have read and understand the
content of this form and also the before and after treatment plan. I give consent for treatment to be carriedout by the practitioner and that my details remain confidential, except when sharing information for data,training and research. I acknowledge that the information released may include protected and individuallyidentifiable information about me. I confirm that the information on this form is correct and accurate and nomaterial information has been omitted. If I become aware that any of the information in this form is incorrector out of date, I will inform my Hijama & Alternative Therapy Practitioners immediately. I authorise the releaseof this form to my Hijama & Alternative Therapy Practitioners and to The Yorkshire Hijama & AlternativeTherapy Clinic & Associated Health Professionals.
Practitioner Notes :Treatment Given :
After Treatment (How the Patient felt)
Patients Signature
Guardian or Spouse Signature
Practitioners Signature
Print Name
Print Name
Print Name
Date
Date
Date