What is your age?*

What is your occupation?*

Are you currently under the care of a physcian?*

What is the reason for todays visit?*

What are you goals for todays session?*

What medications are you currently taking?*

List and prioritize your current symptoms/issues*

Are you currently pregnant ?*

Do you have High or low Blood pressure? If so list which one *

Do you have a history of Heart disease, vericose veins , asthma, stroke, cancer, degenerative disorders, neurological disorders, HIV, Hepatitis or any contagious disease or condition? *

Do you have any known allergies?*

Is there anything about your health history you think I should be aware of?*

I consent to "before and after" photographs and videos for the purpose of documentation,potential advertising, and promotional purposes.

By typing my full name I give Heather Trump permission to perform Massage and Bodywork services and hereby release her of any liabilities. *