Questionnaire for Cupping Therapy Please enable JavaScript in your browser to complete this form.Type of therapy needed *Fixed/Moving CuppingHijama CuppingYour name *Email address *Phone no *Zip code *Your age *Reasons for seeking this therapy *Current medical conditions (type "NA" if no medical issues) *Have you had cupping therapy done before? *Yes, Fixed/moving cuppingYes, Hijama cuppingNeitherPlease check the conditions below that apply to you *DiabetesEpilepsySevere EdemaCancerCurrent fracturesActive shinglesCuts/abrasionsRecent sprains/strainsSkin disordersHeart conditionsGoutHigh/low blood pressureThrombosis/EmbolismNerve dysfunctionUndiagnosed lumps on bodyVaricose VeinsLacerations/UlcersContagious diseasesOrgan transplantRecent injuries/surgeriesRecent hemorrhageSunburn/windburnWarts/skin tagsBleeding disordersI am completely healthy and have none of the aboveAgreement 1: For Hijama, a small amount of blood is extracted from the skin on the cupping sites by making a number of 3-4 mm small shallow incisions with a size 15, single use, sterile blade. All blood items such as cups, blades, needles and tissues are single use only and not reused. Following the procedure, the cupping sites are cleaned up, sanitized, and sealed with coconut oil. *I understand the procedureI am not comfortable with these proceduresNot applicable - I am not doing Hijama cuppingAgreement 2: I understand that cupping therapy and Hijama therapy is not meant to treat any specific illness, and that Hijama Cupping in particular is a holistic Islamic spiritual practice for the benefit of mind/body/spirit, and that this cupping therapist at Your Safe Living is not a qualified medical professional, cannot diagnose or treat any illness, and not qualified to prescribe any medications. I understand that if I proceed with either of these cupping therapies, I do so at my own diligence and risk and after any due consultation with my physician. I understand that absolutely no warranties or guarantees are provided whatsoever. I hereby release this cupping therapist, Your Safe Living, its employees or contractors from any and all liability. *I agreeI do not agreeSubmit
