Patient Medical History Form
This form must be completed by the patient BEFORE treatment. It must be understood, recorded and signed as part of the medical questionnaire. 
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Full Name *
Date of Birth  *
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Address / Post code *
Phone number *
I would like cupping for 

 Advisory

ADVICE BEFORE CONSIDERING HIJAMA: 

Hijama, otherwise known as wet-cupping is a traditional means of alternative therapy. It is highly recommended to seek medical advice from your doctor or any other professional or medically licensed healthcare provider. If you are currently undergoing medical treatment of any sort or think you may be suffering from a medical condition, you must consult with your doctor prior to a consultation with a therapist. You should not disregard medical advice or discontinue a medically prescribed treatment due to undergoing Hijama therapy. 

 

NOTIFYING YOUR GP/DOCTOR: 

All patients are responsible for notifying and discussing their suitability for undergoing Hijama therapy with their licensed medical healthcare provider. Any responsibility post-hijama must be assumed by yourself if you do not do so. It is highly recommended that women who are sexually active carry out a pregnancy test prior to attending their consultation – If you are pregnant, you must not undergo Hijama under any circumstances. 

 

PATIENTS USING PRESCRIPTION MEDICINE: 

Patients who are using prescription medicine must notify the clinic 2 weeks prior to booking their 1st  session. 

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GP Name and number 
Please list all medication you are taking. If not type N/A *
Next of Kin details in case of any emergency (Please include Kin Name, Number and Relation to you)  *
Do you have diabetes ?  *
Are you registered with any Disability ? *
Required
Have you been hospitalised within the last 12 months? If yes please provide information.
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Do you have any known allergies? If yes, please specify below: 
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Do you have any specific skin conditions such as eczema, psoriasis, keloids etc? 
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Are you prone to hyperpigmentation/scarring?
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Have you been diagnosed with any psychiatric or mental illnesses? 

i.e. panic attacks or depression.

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Are you suffering from any spiritual afflictions? 
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If yes for question above, How long for and what type? 

Further Information

Whilst cupping therapy has no major side effects and is a traditional technique that has been used a remedial cure for several  centuries, it is to be understood by all our patients that there are side effects that can occur as a result of undergoing therapy. Individual medical history is a cause of variance therefore you MUST discuss any concerns with your therapist. 

Also, it should be understood and accepted that marks from the superficial incisions, in some circumstances, may last for a timeframe of up to 4 weeks to several months. The marks appear circular in shape and with a bruise-like tone or discolorations where the cups were applied. There may be some discomfort experienced due to methods of cutting as well as ones individual healing process. 

There is a possibility of feeling unwell following the days of being cupped – This is normal and is a result of your body adjusting, resetting and recovering. 

You will be advised upon other potential side effects such as dizziness, numbing, hyperaemia etc, however will be advised on how to deal with these effects. Please address all concerns with a therapist beforehand. 

We take Photos/Videos of your session to send you after. We may use this on social media but will not include your face or anything to give away your identity.

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I understand that After Hours Cupping will not accept liability or expenses resulting from any illness, injury or other untoward occurrence arising from the conduction of Hijama other than to the extent that death or personal injury arises as a result of negligence. 

I confirm that the information provided regarding my mental and physical health is correct to the best of my knowledge and a true representation of my medical history, present and past. I understand that by providing false information, I endanger both my own safety and potentially the wellbeing of my therapist. I am willing to assume any responsibility which results from negligence on my behalf. 

I have read and understood the above and agree to proceed with Cupping appointment. 

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Signature - Print name in block capitals *
Cupping is mainly preformed on the back - we will tailor your session according to the information provided above and the package you choose. Please visit Click here to see all packages available.  
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