Client Intake Form

HOLISTIC HANDS

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New Client Intake Form

* Indicates required field

Email *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

What service are you booking today? *

Reflexology AromaTouch Reiki Bio-Well Energy Infrared Therapy Distant Reiki Reflexology Lymph Drainage

Please provide a brief medical history including accidents, injuries, surgeries, allergies, if you are currently receiving any medical or psychological treatment, or taking any medications for known medical conditions? *

Are you currently pregnant? If yes, how far along are you? *

Are you currently receiving other alternative treatment? If yes, please specify *

Do you have difficulty lying on your front, back, or side? if yes, please explain. *

Have you had Reflexology, Reiki, AromaTouch before? If yes, when was your last session? *

Please reate your stress level (0=None to 5 being severe *

0 1 2 3 4 5

Where do you hold your tensions? *

Do you have any of the following on your feet, or anywhere else on your body? check all that apply *

Athlete's Foot Claw Toe Hammer Toe Dry, flaky skin Plantar Warts Soreness/Tenderness Varicose Veins Broken Bones Calluses Rash Swelling Bunion Corns Scars/past Injury Current Injury Neuroma Sensitivity

Do you have a particular area of concern you would like to discuss today? *

What is your intention for today's session? *

How did you hear about us? *

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