Client Intake Form 11. Personal Information22. Health History33. Wellness Goals44. Informed Consent & Acknowledgement55. Liability Waiver & Disclaimer Full Name First Date of Birth MM slash DD slash YYYY Phone NumberEmail Address Address City State ZIP Emergency Contact NameRelationship Phone: Do you currently have or have you ever had any of the following conditions?Heart disease or pacemaker Respiratory conditions (e.g. asthma, COPD) Seizure disorder Pregnancy or breastfeeding Cancer or undergoing chemotherapy Recent surgery or hospitalization High or low blood pressure Metal implants or medical devices Current smoker or recent tobacco use Please list any allergies, including medications or substances:Are you currently taking any medications or supplements? Yes No HiddenIf yes, please list: What are your main reasons for trying Hydrogen Inhalation Therapy? General wellness/anti-aging Detoxification Detoxification Athletic recovery Energy boost Other HiddenUntitled ____ I understand that Hydrogen Inhalation Therapy is not a substitute for medical diagnosis or treatment. ____ I have disclosed all relevant health conditions to ensure safe application. ____ I understand that while generally considered safe, hydrogen therapy may not be appropriate for everyone. ____ I agree to communicate any discomfort or unusual sensations during the session. ____ I give my voluntary consent to participate in hydrogen inhalation therapy. I confirm that all information provided is accurate to the best of my knowledge.Client Signature Date MM slash DD slash YYYY Staff Initials
