Full Name

Birth Date

Phone Number

Email Address

Emergency Contact

Emergency Contact Phone

Please list any medications or natural supplements that you are taking:

Please list any areas of concern relating to physical - emotional - or energetic tension

Present Pain Levels if applicable (select a number between 1 and 10) Present Pain Levels if applicable (select a number between 1 and 10)12345678910

Present Stress Levels if applicable (select a number between 1 and 10) Present Stress Levels if applicable (select a number between 1 and 10)12345678910

Please select if you have or have had any experiences with any of the following: Please select if you have or have had any experiences with any of the following: Headaches/migraines Depression/anxiety Insomnia Allergies/sensitivies Arthritis Diabetes Joint replacements High/low blood pressure Neuropathy Cancer Fibromyalgia Stroke Heart attack Numbness/tingling Sprains/strains/dislocations Skin conditions Pregnancy Recent injuries

Please explain any other information that you would like to inform me of before our treatment: