Health Assessment Form

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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 48 hours BEFORE your scheduled session.

Email *

Name *

Phone Number *

Birthdate *

YYYY

Occupation

Hours worked per week

Status

Single

In a relationship

Married/Engaged

Clear selection

Children? Pets?

Yes

Clear selection

Medical History

Height

Weight

Eye Color

When was the last date of your last menstrual cycle?

YYYY

Do you have high blood pressure? *

Yes

Do you have any allergies? *

Yes

If yes, please list all allergies

Do you have any sensitivity to oils/incense? *

Yes

How is your Elimination?

Multiple times a day

Daily

Every other day

A couple times a week

Clear selection

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:

Have you ever received a healing session before? *

Yes

If so, what?

Reiki

Thai Yoga Therapy

Ayurvedic consultation

Crystal/Energy Healing

Other:

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Anything else you'd like to share?

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