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Hilot Clients Form Wellness

The document contains a client's medical record form with sections for vital signs, medical history, present illness, and consent for therapy. It collects information such as name, address, age, contact number, blood pressure, temperature, pulse rate, respiratory rate, existing medical conditions, details of present illness, and signatures for consent.

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Apple Joyce Caluza
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We take content rights seriously. If you suspect this is your content, claim it here.
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220 views

Hilot Clients Form Wellness

The document contains a client's medical record form with sections for vital signs, medical history, present illness, and consent for therapy. It collects information such as name, address, age, contact number, blood pressure, temperature, pulse rate, respiratory rate, existing medical conditions, details of present illness, and signatures for consent.

Uploaded by

Apple Joyce Caluza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CLIENT’S RECORD

Name: _____________________________________________ Date: ______________

Address: ___________________________________________ Time: _____________

Age: _______________

Contact Number: __________________________________

VITAL SIGN

Blood Pressure: ____________________________________

Body Temperature: ________________________________

Pulse Rate: ________________________________________

Respiratory Rate: _________________________________

MEDICAL RECORDS

Diabetes What Type?

Hypertension Major Surgery

Heart Disease Chest Pain

Seizure Disorder Fall Fracture

Trauma Itchiness

Allergy Tuberculosis

Respiratory Problem Asthma

Bronchitis Easy Fatigability

Present Illness:
If painful when is started? YES NO
It is on and off pain? Fever Swelling

I __________________________________ is subjecting myself for therapy

Recommended for Massage? YES NO

______________________________ _______________________________
Client’s Signature Therapist’s Signature Over Printed Name

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