Health Assessment Form
This form is completely confidential and lends insight on your overall health and how I can best prepare and maximize your session. Please leave empty anything you do not feel comfortable answering and email it back to me at least 24 hours BEFORE your scheduled session.
Email address *
Name *
Your answer
Phone Number *
Your answer
Birthdate *
MM
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DD
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YYYY
Occupation
Your answer
Hours worked per week
Your answer
Status
Children? Pets?
Medical History
Height
Your answer
Weight
Your answer
Eye Color
Your answer
When was the last date of your last menstrual cycle?
MM
/
DD
/
YYYY
Do you have high blood pressure? *
Do you have any allergies? *
If yes, please list all allergies
Your answer
Do you have any sensitivity to oils/incense? *
How is your Elimination?
Please list any medical conditions or illnesses. *
Your answer
Please list any injuries/surgeries and/or hospitalizations you’ve had in the past 10 years. Please include years. *
Your answer
Please describe your regular exercise habits: *
Your answer
Please describe your eating/drinking habits:
Your answer
Goals
Tell me a little more about you and your goals so that I may tailor your session according to your needs.
Have you ever received a healing session before? *
If so, what?
What health concerns would you like to address? What are you seeking to achieve through holistic care? *
Your answer
Anything else you'd like to share?
Your answer
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