Intake form: Health Questionnaire

Do you or have you suffered from any of the conditions below? *

Yes

Epilepsy

Migraines

Spinal or other fractures

Bladder problems

Asthma

Heart condition

Osteoperosis

Skin Conditions

Diabetes

Joint problems

Cancer

High Blood pressure

Varicose veins

Other

If you have answered 'YES' to any of the above, please give details
Goal for the session
Are you pregnant, or have you been pregnant within the last year?

Yes No
I have read, understood and completed this questionnaire. I understand that stretching sessions may lead to some muscle soreness for a few days after treatment.

All the information I have given above is correct to the best of my knowledge.
Signed
Date
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