Some info to open the door . . .

Fill out this questionnaire. This will help me attune to your specific needs before you arrive.

Name

First Name

Last Name

Email

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate

MM

DD

YYYY

Age

Occupation

What is your present stress level?

Low

Medium

High

Please state any Rx medication you are taking, and what it is for:

Please list any history of surgeries, major illness, chronic conditions, accidents, injuries, psychological or psychiatric care:

Please list digestive related problems (stomach, constipation, heart burn) if any, and allergies:

Women: When was your last period? How does it affect you?

What do you do for fun and relaxation?

Some info to open the door . . . Some info to open the door . . .