BHD Healing Intake Form

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First Name *

Last Name *

Email Address *

Phone *

Date of Birth *

Home Address *

Occupation *

Emergency Contact Name *

Emergency Contact Phone *

Medical Details *

Please check all that apply and add anything else whether it seems relevant or not.

No problems, in perfect health

Back Pain

Physical Disability

Nervous Disorder

Allergies

Migraine Headaches

High/Low Blood Pressure

Heart Disease

Epilepsy

Asthma

Diabetes

HIV+

Hemophilia

Cancer

Other:

Required

Joint Injuries or Surgery (please elaborate)

Are you taking any medications? If yes, please list them.

Please include anything, even herbal supplements or holistic treatments, as these can affect you.

What regular activities, athletics, or sports do you do?

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