Demographics & Health History Form
Full Name
*
First Name
Last Name
Date of Birth?
*
What is your age?
*
What is your gender?
Please Select
Male
Female
N/A
Contact Number
*
Email Address
*
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Number
*
Employment Status
*
Self-Employed
Employed
Unemployed
Student
Retired
Occupation
*
Place of Employment
*
How did you hear about us?
Facebook
Instagram
Tictok
Other
Check the conditions that apply to you ?
*
Asthma
Blood disorder
Chronic Back Pain
Constipation/Diarrhea
Depression/Anxiety
Diabetes
Endometriosis/Adenomyosis
Epilepsy
Hair Loss
Heart Disease
High blood pressure
HIV
Hypothyroid
Joint/Muscle Pain
Migraines
Mental Health Diagnosis
Neuropathy
Skin disease
Stroke
Spiritual concern
PCOS/Firbroids
Photosensitivity
Pregnancy
TMJ
Weight gain
Other
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
Are you currently taking any medications or herbal supplements?
*
Yes
No
Please list them.
Have you had any surgery?
*
Yes
No
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Treatment
What is your goal or desired results?
ex. Weightloss, Body Contouring, Stress/Anxiety management, Natural pain/Inflammation management, Hormonal Balance, Digestive Issues, Grief, Chronic or Autoimmune disease management/prevention
Have you had health coachings in the past?
Yes
No
Any experience or interest in meditation?
Yes
No
Do you exercise?
Yes
No
Please provide what exercises and how often?
ex. 20-30min HIIT training 3-5days a week.
Have you holistic therapies in the past?
Yes
No
N/A
Please provide details of previous therapy and outcome of results.
Have you had body contouring therapies in the past?
Yes
No
N/A
Please provide details of previous therapy and outcome of results.
Do you own a fitted compressions garment or faja?
Yes
No
Services
For more information on each of the services, please visit our website at
For more information on our services please visit our website at alignbyzen.online or scan the QR code below
For more information on each of the services, please visit our website at
We have pre-selected the "Free Consultation" option. Please feel free to select any other services of interest.
*
Free Consultation
Coaching Package- Personalized guidance, customized plans, weekly support, and free monthly workshops - included with every package for a holistic approach to wellness.
Mindful Serenity- Find peace and calm in our Mindful Meditation sessions, expertly guided to quiet your mind, soothe your body, and uplift your spirit.
Head Spa- choose between a Crown Head Spa Massage for relaxation or a hair growth stimulation or Crown Bliss all the benefits with no water therapy)
Align the Body- Choose from a wide variety of massages: Relaxation, Tension releasing, Lymphatic Drainage, Foot Reflexology, and Digestive Balance.
Natural Body Contouring- Wood Therapy, Oiled Sauna and Weightloss CryoTshock
Athletic Injuries, Acute/Chronic Pain Relieve CryoTShock
Herbal Bliss- Includes a free consultation for customized tea blends and infused oils.
Signature
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