Philosophy /  Message & Bio From Sylvanus

Health History Form

Please take a few moments to fill out this form so that we can better serve your needs:

 

 

6. Check all the words that best describes your daily working activity:

 
7. Has your doctor, at any time, restricted you from strenuous activity?     
   
8. Have you ever been told your blood pressure was high?    No  
   
9. Have you ever been told your blood pressure was low?     
   
10. Are you troubled with dizzy spells or light-headedness?     
   
11. Do your veins ever ache?     
   
12. Do you have frequent headaches / migraines?     
 
13. Have you ever been told you have any of the following illnesses?:
a) Trouble with your heart     
b) Heart attack, coronary, myocardial infraction     
c) Angina, heart pain     
d) Heart murmur     
e) Heart disease     
f) Rheumatic heart     
g) Stroke     
h) Arteriosclerosis     
i) Diabetes     
j) Emphysema    
k) Asthma or allergies     
l) Chronic bronchitis     
m) Chronic fatigue? (Epstein Barr)     
n) Gout     
   
14. Have you ever been diagnosed with:
a) Rheumatoid arthritis     
b) Osteo arthritis     
c) Degenerative disc   
d) Spine disease   
e) Spinal Fusion     
f) Shoulder / elbow / hip / knee bursitis     
g) Cartilage or ligament problem of the knee     
h) Hyperglycemia     
i) Hypoglycemia     
j) Underactive thyroid    No 
k) Overactive thyroid     
   

 
16. Have you ever been in an automobile / sports or other accident?     
   
17. Are you pregnant?     
 
18. Have you ever been on drugs for:
a) Blood pressure     
b) Cardiovascular     
c) Heart     
d) Diet     
   
19. Do you smoke?   

 

 

 




Home
News
Classes
Schedule
Fees
Events
Health History Form
Registration
Location
Words of Gratitude

Contact Information:

Address
562 Ontario Street
Toronto, ON
Canada
M4X 1M7
 
Telephone
 416-921-1304

Email
 admin@reinodojo.com

 


Copyright by Sylvanus Klotz 2007 All Rights Reserved
562 Ontario Street . Toronto  .  ON .  M4X 1M7