• Spinal Flow Technique Health Questionnaire

    Please fill out this form and submit before your appointment date.
  • Appointment Date*
     - -
  • Format: (000) 000-0000.
  • Preferred Contacts*
  • Birth Date*
     - -
  • Birth Time

  • About Your Health

    The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nerve system, which have resulted in poor health. During your sessions we will begin to correct these layers of damage and recover your innate health potential.

  • Loss of Wellness (Birth - Age 5)

    Let's begin at birth when you may have first damaged your nerve system, lost your wellness, and began your journey to ill health.

  • Birth Process

    Please check the appropriate answer and add comments where applicable.
  • Was the delivery long and/or difficult?
  • Were Forceps or suction used?
  • Was the birth Cesarean?
  • Do you know of any stressful situation that may have been present for your mother or father or both?
  • Any Childhood Accident or illnesses?
  • Did you have other childhood traumas?
  • Did you have colic, reflux or difficulty feeding?
  • Were there any stressful events that occurred in this time?

  • Loss of Whole Body Health (Age 5 - Present)

    As you increase the layer of damage you probably begin to experience symptoms and random bouts of sickness.
  • Did you / Do you smoke?
  • Do you / Do you drink Alcohol?
  • Did you / Do you take recreational Drugs?
  • Do you take over the counter Drugs? (Prescriptive or Non-prescriptive)
  • Diet (do you eat healthy?)
  • Have you been in any Accidents?
  • Have you had surgery and organs removed or replaced?
  • How's your sleep?
  • Do you have any allergies?
  • Sleep posture
  • Did you / Do you have occupational stress?
  • Do you have physical and/or Mental stress?
  • Do you have hobby / sports injuries?
  • Are there any other traumas or problems?
  • Were there any stressful events that have caused an impact on your health and wellbeing?
  • Have you had any trauma or abuse in your life?

  • Present State of Health (Symptoms)

  • Is this condition interfering with:
  • Are you living the life you would like to be?
  • Are you ready to make changes to your life in order to heal, even if these changes could be inconvenient to your lifestyle?

  • Any other symptoms, feelings or emotions you are experiencing?

    Please check all applicable
  • I am experiencing: (Base)*
  • I am experiencing: (Foundation)*
  • I am experiencing: (Power)*
  • I am experiencing: (Center)*
  • I am experiencing: (Passion)*
  • I am experiencing: (Pause)*

  • Agreement, Consent, and Signature

  • By signing this form, I agree and consent to the healing work while I am on this treatment period. 

    I understand that with any healing process and work on my body, my symptoms may worsen before they get better. 

    I understand this program is designed to assist the body with healing by helping to remove stressors from the body.

    I understand that healing takes time and there is no quick immediate fix to my problem, and health is a process. 

    I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment. 

    I agree and accept the Appointment and Privacy Policy, and the Terms & Coonditions below:

    Appointment Policy

    Privacy Policy

    Terms & Conditions

  • Thank You! We look forward to meeting you soon.

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