Client Health Questionnaire

Client Health Questionnaire

Please complete this form to help us understand your health background and current status.
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
MaleFemaleOther
YesNo
NoneEpilepsyHypertensionHeart DiseaseAsthmaDiabetesOther
Please list any medications you are currently taking.
Lower BackPain in Mid-SpineNeckShoulderArmChestPelvisKneeHipLegFibromyalgiaOther
No known allergiesMedicationsFoodsEnvironmentalEssential oilsOther
Sleep disorderSnoreRefluxSinusDigestive issuesFaintingBalance LossStressThyroid IssuesMenopauseHearing ProblemsDepressionFatigueNervousnessConstipationDiarrheaPins & NeedlesDifficulty BreathingOthersNone
What are your current health concerns or symptoms?*
YesNoFormer smoker
How would you rate your overall health?

1

2

3

4

5

1 is Poor, 5 is Excellent
YesNo
What are you wanting to get out of these sessions?*
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Before signing this form, I agree and consent to the healing work of The Spinal Flow Technique™ .

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

I understand this 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 problems, and health is a process.

I have freely decided to undergo the recommended treatment and hearby give my full consent to treatment.
Yes
Name*

First NameLast Name
Date

MonthDayYear
Date
Signature*
Should be Empty: