Your Name

Date of Birth

Mailing Address

City

Zip Code

Phone

Email Address

Occupation

Do you text? Do you text? Yes No

Emergency Contact

Relationship

Phone Number

Have you received a Covid 19 Vaccination? Have you received a Covid 19 Vaccination? Yes No I prefer not to answer

Have you been confirmed positive with COVID-19? Have you been confirmed positive with COVID-19? Yes No

Have had any COVID-19 symptoms in the last 14 days; fever, cough, shortness of breath? Have had any COVID-19 symptoms in the last 14 days; fever, cough, shortness of breath? Yes No

Have you been in close contact with individuals who have been confirmed positive for COVID-19? Have you been in close contact with individuals who have been confirmed positive for COVID-19? Yes No

Have you recently traveled to an area that is considered a COVID-intensive area? Have you recently traveled to an area that is considered a COVID-intensive area? Yes No

Have you been in contact with other individuals who have traveled to a COVID-intensive area and are exhibiting acute respiratory illness symptoms? Have you been in contact with other individuals who have traveled to a COVID-intensive area and are exhibiting acute respiratory illness symptoms? Yes No

Do you have an Autoimmune Disease? Do you have an Autoimmune Disease? Yes No

Do you experience blood clots? Do you experience blood clots? Yes No

Have/Had cancer? Have/Had cancer? Yes No

Experience abnormal skin condition? Experience abnormal skin condition? Yes No

Do you have High/Low Blood Pressure? Do you have High/Low Blood Pressure? Yes No

Do you have Varicose Veins? Do you have Varicose Veins? Yes No

Do you have Diabetes? Do you have Diabetes? Yes No

Do you experience Headaches or TMJ Do you experience Headaches or TMJ Yes No

Do you have structural/muscular concerns? Do you have structural/muscular concerns? Yes No

Please indicate specifics in structural/muscular Concerns

Are you pregnant? Are you pregnant? Yes No

When is due date?

If any, please state any health concerns regarding your pregnancy.

Please list any other Health Concerns

Signature - Please type your name as an E Signature, indicating that you have read/answered the above questions.

Current Medications

Signature