M

F

1. Do you have an OPEN WOUND(s)?

2. Do you have or have had any of the following Disorders that affect the Brain, Nerves throughout the body and/or spinal cord?

No

Yes

Stroke

Multiple Sclerosis Disease

Epilepsy

Parkinson's Disease

Carpal Tunnel Arm

Neuropathy

Diseases of the brain

Dementia

Alzheimer’s Disease

Neuralgia (pain in nerve)

3. Do you have any of the following ARTHRITIS?

Fractures

Osteoporosis

No

Yes

Yes

No

If yes, explain in brief detail these or any other ARTHRITIS problems if needed:

4. Are you DIABETIC?

Yes

No

Diabetes Type 1

Diabetes Type 2

Diabetic Neuropathy

Hypothyroidism

5.Do you have HEART PROBLEMS?

Yes

No

If yes, describe and/or choose from the following choices:

Congestive Heart Failure

Coronary Artery

Pacemaker

Stent in Heart

6. Do you have HIGH BLOOD PRESSURE?

Yes

No

7. Do you have KIDNEY DISEASE/KIDNEY FAILURE?

Yes

No

8. Do you have LUNG DISEASE?

Yes

No

If yes, describe and/or choose from the following choices:

COPD

Asthma

Oxygen

Pneumonia & Tuberculosis

Lung Cancer

9. Do you have ANXIETY/BEHAVIORAL DISORDERS?

No

Yes

If YES Select all from the following which Applies

Bipolar Disorder

Depression

Anxiety

Psychosis/Schizophrenia

Alcohol/Opioid Abuse

OCD (obsessive-compulsive disorder)

PTSD

Panic Disorder

Social Phobia (social anxiety)

10. Do you have CANCER?

Yes

No

If yes, briefly explain your condition:

11. Select if you are DIAGNOSED with any of the following:

UTI-Urinary Infection

HIV

Aids

Hepatitis

I

I here by agree to all terms of this form. (Check to Confirm)

                                                               authorize Gentle Consultant Agency to release my medical information including diagnosis, records, and to any Medical Agency that will further assist my needs.

Signature

TYPING YOUR NAME ABOVE SERVES AS A VALID SIGNATURE OF APPROVAL.

Date

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