Client Health Questionnaire

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All information shared will remain confidential.

电子邮件地址 *

Name *

Age *

City *

Phone number *

Occupation *

What is your intention seeking bodywork? *

Have you received bodywork before? If so, how was your experience? *

Is there any emotional healing you would like to explore? *

Please check any that currently apply:

Muscle/Joint Pain

Diabetes

Anxiety, Stress

Osteoporosis

Pregnancy

Depression

Arthritis/Tendonitis

Sleep Difficulties

PTSD

Numbness, Tingling

Bi-polar

Allergies

Cancer

Varicose Veins

Circulatory Problems

Asthma

Blood Pressure

Respiratory Problems

Digestive Problems

Infectious Diseases

Disassociation

Body Image Distortion

Boundary Issues

Flashbacks

其他:

Are you currently taking any medication?

Are you allergic or sensitive to:

Nuts

Fragrances

Primary goal(s): (Please check all that apply)

Relaxation

Stress Relief

Relief of pain or tension

Injury rehabilitation

General health maintenance

Improve movement & flexibility

Emotional healing

Increase body awareness

Specific condition

其他:

Anything else you feel pertinent to share that wasn’t asked?

Referred By:

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