Yoga Plus Reflexology Health form

705-294-1228 or 905-251-0129

www.yogaplusmore.com

NAME:___________________________________________________________________

ADDRESS:_________________________________________________________________

PHONE NUMBER:___________________________________________________________

EMAIL;_____________________________________________________________________

IN CASE OF EMERGENCY CONTACT NUMBER ________________________________________

DOCTOR ______________________________________________________________________

DOCTOR TELEPHONE NUMBER____________________________________________________

HIGH BLOOD PRESSURE___________________________________________________________

ARE YOU PREGNANT?_____________________________________________________________

OPERATIONS____________________________________________________________________

ARE YOU UNDER STRESS?__________________________________________________________

HEALTH PROBLEMS________________________________________________________________

PLEASE COMMENT ON YOUR  HEALTH PROBLEM SYMPTOMS_________________________________

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SLEEP PROBLEMS___________________________________________________________________

WHAT IS YOUR EXERCISE LEVEL 1-(10)__________________________________________________

WHAT IS YOUR DIET AND NUTRITION LIKE?  PLEASE COMMENT_____________________________

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DO YOU SUFFER FROM BUNIONS?_______________________________________________________

DO YOU SUFFER FROM CORN OR TOE NAIL PROBLEMS PLEASE COMMENT______________________

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ARE YOU SUFFERING FROM BROKEN BONES DUE TO AND ACCIDENT____________________________

PREVIOUS REFLEXOLOGY TREATMENTS____________________________________________________

THERAPIST____________________________________________________________________________

DATE ________________________________________________________________________________

HOW DID YOU HEAR ABOUT US ____________________________________________

AGE______________________________________________________________________________

SEX_______________________________________________________________________________