Health History Form

Step 1 of 5

  • My Referral Reward Program

    Did someone refer you? Please tell me who so I can thank them. My business grows by referral due to the extraordinary results my clients experience when we work together. Share the value of what I do with three people - when they become a client you get one FREE treatment for yourself. Together, we can make optimal health and wellness possible for each individual in our community (and beyond).
  • Disclosure

    The purpose of collecting this information is to uncover any contraindications and to determine an effective course of treatment. Please be honest in your answers. All information will be kept confidential.
    How often do you receive professional bodywork (ie. Massage, CranioSacral Therapy, Reiki, Thai massage or other forms of therapy)?
  • Activities of Daily Living