How did you hear about me?
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
City, State, Zip code
Date of Birth/age
MM
DD
YYYY
Emergency contact & number
Do you have a chief complaint? Please share if you do.
Please describe your current symptoms. How often do you experience it? When do you notice it most?
Are you in pain?
Is the pain localized or does it radiate to other areas of your body? Please describe the pattern.
Was there an episode that triggered your current symptoms? Please describe.
Are you currently on any medication for the pain? If so, what is the medication(s)?
Are you participating in any other type of therapy to address this issue? Please list.
What is your occupation?
Please describe your day-to-day. What is your lifestyle schedule like?
Please rate your current stress level?
How is your daily energy level?
Are you physically active? What is your regimen?
How is your sleep pattern? How many hours?
How do you sleep? (on your back, side, stomach or combo)?
Are you participating in any other type of therapy? Bodywork/healing modality?
Please indicate any medical conditions past or present:
acid reflux, arthritis, blood pressure (high or low) cancer- if so what type, chronic fatigue syndrome, depression, fibromyalgia, lupus, TMJ, Thryoid (Hyper or Hypo), etc.
Do you have a history of any sprains, strains, broken bones? And when did it happen?
History of any surgery?
Are you currently under a physician’s care? Is it for this condition or something else?
Have you ever had a massage? When was your last massage?
What is your preferred depth of pressure during the session?
List other types of bodywork and/or energy work you have experienced.
Are there sensitive or ticklish areas I should be aware of?
What kind of music would you enjoy hearing during your session, from Spotify?
CHECK ALL THAT APPLY
Are you interested in incorporating essential oils during your session?
If YES, What is your experience with Aromatherapy? Have you used essential oils before?
Please check all aromas you like?
Do you have allergies to plants/herbs? If so, what are they?
Aromatherapy has a multi-faceted impact to your entire wellbeing, mentally, emotionally, and spiritually. Is there an intention that I can help support you with during our session with essential oil? What may/could that be?
Are you interested in a custom crafted signature aroma blend to support your wellbeing?
As a Certified Aromatherapist, the power of scent in essential oils can help therapeutically shift and balance your psyche and spirit.
How do you prefer to receive confirmation of your appointment?
text only
email only
both are fine
May I include you in our community email list for promotion of my services and products (Root and Resin, my handcrafted product line)?
I promise to not spam or give your personal information to any third party, whatsoever.
