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
Gender

Other
Have you had surgery and organs removed or replaced?
Do you have any pre-existing medical conditions?

Other
Please list any medications you are currently taking.
Are you suffering any pain? ( Please tick if applicable)
Do you have any allergies?

Other
Do you have any of the following?
What are your current health concerns or symptoms?
Do you smoke?
How would you rate your overall health?

1

2

3

4

5

1 is Poor, 5 is Excellent
Do you exercise regularly?
What are you wanting to get out of these sessions?
Notes - Is there anything else you would like to add?
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.
I agree with the above statements
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Should be Empty: