Lisa Fabry Natural Healing
Client Information Form
MOVEMENT THERAPY
Please fill out this form and press SEND at the bottom of the page to submit. All information is confidential and it will be stored securely.
Name
Today's date
Date of birth
Address
Email
Phone number
Occupation
Emergency contact
Other practitioners you see
What are your three main health and wellbeing goals?
Yoga / Qigong experience?
Do you currently have any kind of meditation or self-reflection practice?
Equipment
PERSONAL HEALTH HISTORY
PLEASE DESCRIBE ANY HEALTH ISSUES YOU CURRENTLY HAVE
Please also complete the self-evaluative 'Adult Pre-Exercise Screening Tool' that I have sent you.
Digestion
Energy and Immunity
Breath
Heart
Urinary
Skin
Músculo-skeletal
Pain
Headaches
Mental health
Sleep
Any other health issues
DIET
OTHER INFORMATION
Please list any medication you take including prescribed drugs, over-the-counter medicines and supplements.
Do you have any known allergies or sensitivities?
Is there anything else you would like me to know?
Send
lisa@lisafabry.com
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Name
Email
Yes! Please send it to me!