Client History

Please review the document below, download it, complete all required sections, and return it via email to GingkoTherapy@gmail.com.

What is your past medical history (ex. heart, respiratory, broken bones, surgeries, falls, accidents, high blood pressure, diabetes, etc.)?

Are you waiting for the results of any medical procedure or test; please list. Are there any findings from MRI, CT, or X-rays that you’ve had in the last 10 years?

Do you have any scars from previous surgeries, procedures, or injuries? Please name them all.

Do you have any abdominal surgeries or conditions, such as mesh implantation, IBS, Diverticulitis, Hernia, Gastric Bypass, or Celiac Disease?

Do you have any chronic conditions, such as Rheumatoid Arthritis, Fibromyalgia, EDS, Osteoarthritis, Osteoporosis, POTS, Hashimoto’s, or any other?

Are you pregnant, or is there any possibility you may be pregnant?

Are you experiencing any pain? If so, describe all the painful areas in detail.

Do you have a pacemaker or any other implants?

Do you suffer from migraines or headaches?

Do you have any incontinence issues? Please describe.

Are you currently taking any medications? If so, please list them and their dosages.

Agreement The above questions have been answered to the best of my knowledge and are believed to be true. I have not withheld or concealed any information.