Personal Health HistoryName First Last Date of Birth (dd/mm/yy)OccupationAddress Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone (day)Email Emergency ContactPhoneRelationshipHow did you hear about Structural Integration?Medical Information1. Are you taking any medications? Yes No If yes, please list name and use:2. Have you ever had a Motor Vehicle Accident? Yes No Year, type and injuries?3. Please list any surgeries – reason, and month/year of surgery.4. What hobbies or activities do you do?5. What areas are currently causing you discomfort or pain?6. Do you suffer from chronic pain — same as above? Yes No Please describe.What makes it better?What makes it worse?Heart attack/ Heart disease current past Stroke/ Aneurism current past Pacemaker current past Dizziness/ Fainting current past Spinal injury current past Head injury current past Concussions current past Bowel/ Digestive issues current past Fibromyalgia/ Chronic fatigue/ Lupus current past Lymph edema current past Diabetes current past Circulation condition(s) current past Disks: herniated, compressed, degenerative current past Sciatica left right Knee pain/ Dysfunction left right Foot pain/ Dysfunction current past Frozen shoulder/ Rotator cuff issues/ Dysfunction left right Carpal tunnel/ Tennis elbow/Tendinitis left right Whiplash/ Neck pain/ Chronic headaches/ Migraines current past Jaw/ TMJ current past Nerve damage/ Neuropathy current past Joint dislocations - area:Sprains - area:Arthritis - area:Cancer current past Osteoporosis Yes No Hepatitis/ HIV yes no OtherI, the undersigned, understand that Structural Integration is not involved with any treatment of disease of any kind, nor does it substitute for medical diagnosis or treatment when such attention is needed. I understand that it is necessary for Lora Betts, the SI practitioner, to touch my body and I, the undersigned, give her my permission to do so. I also give Lora Betts my permission and consent to do all things necessary in helping me establish balance and alignment, including but not limited to, touching my body. I hereby assume all responsibility to communicate any discomfort or pain during any point in the treatment and release any and all liability or responsibility of Lora Betts. By signing below I agree to the following. I have completed this form to the best of my ability and knowledge. Date I am aware that I must give 24 hours notice for treatment cancellation or a fee may ensue.SignaturePhoneThis field is for validation purposes and should be left unchanged.