Health History E-Form

Barbara Coon, LMT, Heartworks Healing Arts, Inc.
Office Address:
 12036 Phinney Ave N, Seattle, WA 98133  
P:
 206-391-4222 F: 206-556-2177 Tax ID: 91-1681493

Name *
Name
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Date of Birth *
Date of Birth
Address *
Address
Phone # of Emergency Contact *
Phone # of Emergency Contact
HEALTH & WELLNESS
Sleep Habits
provide a baseline for tracking the results of CranioSacral Healing.
Check any sleep issues that apply:
Lifestyle: What do you enjoy?
Current Interests:
Which supportive modalities have you experienced, past or present.
General Information that Influences Your Craniosacral system
Trauma
CranioSacral releases trauma held in the body. Please indicate any of the following that apply to you:
Autoimmune conditions
Please select any conditions that you experience, both past and present.
General Information that Influences Your Craniosacral system
Please select any of the following conditions you are currently experiencing or have in the past.
Headaches
Sinus Issues
Ear Issues
Vision Issues
Dental Issues
Energy & Mood
Muscles and Joints
Nervous System
Today's Date *
Today's Date