Health History Form Personal Information First Name* Last Name* Address* City* Email* Phone Number* Medical Information Pregnant?YesNo Epileptic?YesNo Diabetic/Hypoglycemic?YesNo High Blood Pressure?YesNo Heart Problems?YesNo Varicose Veins?YesNo Arthritis?YesNo If yes, details? Spinal Problems?YesNo If yes, details? Headaches?YesNo If yes, details? (How often, causes, type) High Stress Level?YesNo Details? (Causes, physical manifestation) Allergies Medications Recent Surgeries Amount of sleep Do you wake feeling rested?YesNo Do you use 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, stressreduction and relief of muscular tension. If I experience any pain or discomfort during thissession, I will immediately inform the practitioner so that the pressure may be adjusted to my levelof comfort.The Holistic Practitioner must be aware of existing physical conditions and I have stated all myknown medical conditions and take it upon myself to keep the Holistic Practitioner updated on myphysical health.I understand and agree Submit
