CONFIDENTIAL HEALTH FORM Name * First Name Last Name Date * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number Email * Relationship Status * Occupation * Describe reasons for interest in Yoga Therapy / Rolfing * Describe previous yoga experience, sporting or recreational activities enjoyed * Goals desired with Yoga Therapy / Rolfing * Do you have any numbness, pain, limitations of movement in: * Feet, Ankles, Knee, Sacrum/Hips, Lower Back, Upper Back, Shoulders, Arm, Wrists, Hands, Neck Have you had any surgeries? * If so, on what dates did they take place? Have you had any dental work? * If so, on what dates did they take place? Have you had any accidents or injuries? * If so, when did they take place? Do you have any musculo-skeletal issues? * Eg - ostheoarthritis, rheumatoid arthritis, spinal fractures, ruptured discs, spinal fusion or discectomy, scoliosis, bone fracture within the last 2 years, tendonitis, osteopenia, osteoporosis Do you have any cardiovascular issues? * Eg - high/low blood pressure, previous heart-attacks, strokes, arrhythmia, heart valve complications Do you have any respiratory issues? * eg - asthma, COPD, shortness of breath - and or with exercise, difficulty on inhale or exhale, pain when breathing Do you have any digestive disorders? eg - Recent changes in digestion, low digestion, heartburn or acid reflux, IBS, constipation or diarrhoea, bloating, nausea, stomach pain or any others Do you have any women's health issues? E.g - Absent or painful menstruation, menopause, HRT Treatments, Incontinence Do you have any other health issues such as cancer, diabeties, epilepsy, fibromyalgia, headeaches or migraine? * Please note symptoms, diagnosis, treatment and dates Do you have any endocrine or immune system issues? * E.g - frequent illness, thyroid issues, fatigue or low energy, allergies or food sensitivities Do you have any nervous system issues? * E.g - shakes, numbness, brain fog, headaches or tinnitus How is your sleep? * Do you have difficulty falling asleep? Frequent waking during the night / early morning? Not feeling rested? Are you currently taking any medication? * Including herbal supplements, Please list with reasons What is your prevailing mood / emotional state? * E.g - Joy, Depression, Anxiety, Anger? Describe your typical diet? * E.g - are your mealtimes regular, erratic, late in the evening? Do you drink alcohol? * If yes - how many units per week? Do you smoke? * If yes - how many per day? Do you drink caffeine? * If so how many cups per day? Please list any chronic family health conditions: * How did you hear about MZ Therapy? Thank you!
