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 *
Phone Number *
Birthdate *
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Occupation
Hours worked per week
Status
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Children? Pets?
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Medical History
Height
Weight
Eye Color
When was the last date of your last menstrual cycle?
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DD
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Do you have high blood pressure? *
Do you have any allergies? *
If yes, please list all allergies
Do you have any sensitivity to oils/incense? *
How is your Elimination?
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Please list any medical conditions or illnesses. *
Please list any injuries/surgeries and/or hospitalizations you’ve had in the past 10 years. Please include years. *
Please describe your regular exercise habits: *
Please describe your eating/drinking habits:
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?
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What health concerns would you like to address? What are you seeking to achieve through holistic care? *
Anything else you'd like to share?
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