Name
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First Name
Last Name
Email
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What date is your first session?
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1. What benefits would you like to gain from the session?
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2. Physical Issues: Have you had any recent surgery or health problems such as whiplash, a heart condition, a pacemaker, breathing difficulties, if you are pregnant, please give details here:
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3. Do you take medication or self medicate? If so, please give brief details:
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4. Do you have any particular emotions which predominate in your life, or any unresolved trauma that you are aware of?
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5. Where do you typically hold tension in your body?
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6. a) Do you have any preferred essential oil scents? b) Do you have essential oil scents you dislike or have allergies to? c) Do you have any allergies to base oils?
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7. Do you have any details of your birth that were significant e.g cord around neck, forceps delivery, separated from your mother?
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8. What experience of breathwork do you have?
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9. Anything else you would like to share that you feel is relevant?
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