Health History Form Personal Information First Name: Last Name: Address: City: Phone Number: Email: Medical Information Pregnant? YesNo Epileptic? YesNo Diabetic/Hypoglycemic? YesNo High Blood Pressure? YesNo Heart Problems? YesNo Vericose Veins? YesNo Arthritis? YesNo If yes, details? Spinal Problems? YesNo If yes, details? Headaches? YesNo If yes, details? (How often, causes, type) Stress Level? YesNo Details? (Causes, physical manifestation) Allergies: Medications: Recent Surgeries: Amount of Sleep: Do you wake feeling rested? YesNo Do you go to tanning booths? YesNo How often? Skin type? Treatment Plan What kind of treatments are you interested in? What activities/services do you participate in? (check all that apply) ExerciseYogaDietHerbsVitaminsChiropractorMeditation Other activities/services not listed above: I understand the treatment I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure may be adjusted to my level of comfort. The Holistic Practitioner must be aware of existing physical conditions and I have stated all my known medical conditions and take it upon myself to keep the Holistic Practitioner updated on my physical health. I understand and agree.
