Shiatsu info form
I look forward to seeing you and treating you with Shiatsu. Please fill out this form so that I have a better idea of your specific health state, and how I can treat you. Namaste.
Date of birth
Heart / Small Intestine - Do you have ongoing issues with:
high blood pressure
low blood pressure
Stomach / Spleen - Do you have ongoing issues with:
Bloating / gas
Over-thinking / worry
Lung / Large Intestine - Do you have ongoing issues with:
Grief, loss, and letting go
Kidney / Bladder - Do you have ongoing issues with:
Lack of initiative / motivation
Sore lower back
Bags under your eyes
Feel cold frequently
Early deaths in your family
Urge to urinate in the night
Liver / Gall Bladder - Do you have ongoing issues with:
Anger, frustration or irritability
Frequent alcohol use
Itchy or dry skin
Pain in tendons and muscles
Have you had your gall bladder removed
Can't sit still
Are your periods problematic
General Health Questions
Have you ever had surgery?
Do you have any acute injuries?
Do you have any spinal injuries?
Do you have varicose veins or blood clots?
Do you take prescription medications?
Had you ever been in a motor vehicle accident
Are you pregnant
If you would like to add more details about anything checked above, please do so here:
Are there any areas that would like special attention?
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