New Client Health ConsultationPlease complete this health consultation before your session with me. If in doubt, get in touch Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Daily Activity Please let me know how active or sedentary you are on a typical day. This gives an understanding of what your body goes through during a usual day. Do you have any current or recent injuries? * Yes No If yes, please provide further details here Do you have any of the following health conditions: * Heart condition Diabetes (type I or II) High blood pressure Low blood pressure Migraines Skin issues Bruising Embolism/clots Osteoporosis Arthritis Head/Neck Injury Autoimmune condition Allergies None of the above Please use this space to provide any further or additional details regarding your health that you feel is appropriate Please list any medications or supplements you are currently taking Please let me know what brings you along for your session today it could be relaxation or dealing with a specific issue, or a heady mix of both. please use this space to elaborate so I can make sure your session is right for you. Is there anything else you want to add to your health consultation submission today? * Yes No If yes, please add additional info below Confirmation I confirm that these details are accurate to the best of my knowledge. I agree to update any information should changes happen before my session Consent Thank you, your submission has been securely received.
