Welcome!

The start of our session begins with gathering some basic and important information to inform our work together. Know that this information is confidential and will not be shared beyond us and our session.

So please take a moment and answer the questions below. Do not hesitate to reach out if you have any questions.

Thanks so much and I look forward to seeing you soon. Camellia

Name

First Name

Last Name

Phone

(###)

###

####

Optional: Date of birth and/or age

YYYY

Optional: Exact Time of birth

This information is for astrological purposes

Hour

Minute

Second

Optional: Exact place of birth

This is for astrological purposes.

Line

Name of emergency contact

First Name

Last Name

emergency contact #

CHIEF COMPLAINT

How did you hear about me?

What is your chief complaint?

Please describe your current symptoms:

How often do you experience it? When do you notice it most?

Are you in pain? On a scale of 1 (mild) - 10 (extreme), how would you rate it currently?

Is the pain localized or does it radiate to other areas of your body? Please describe the pattern below.

Was there an episode that triggered your current symptoms? Please describe.

Are you currently on any medication for the pain? If so, what? Is it helpful?

What is your current stress level?

Your lifestyle? Occupation?

How is your daily energy level?

Are you physically active? What do you do? How often?

How is your sleep pattern? How many hours of sleep do you get each night?

MEDICAL

Do you have a history of sprains, strains, or broken bones? List when:

Have you had surgery? If so, where and when?

Are you currently under a physician’s care? What for?

What types of wellness modalities have you received? Please share:

DURING OUR SESSION TOGETHER

Do you have a music preference?

soundscape, instrumental, classical, jazz, blues, silence

What is your preferred depth of pressure?

Do you enjoy therapeutic aromatics?

Aromatic Options and Scent Notes

As an Aromatherapist, I work with essential oils as an aid and tool in sessions. Please check yes to aromas you enjoy!

piney

citrus

woodsy

herbaceous

sweet floral

minty

earthy root

spicey

Follow me on IG @camhandsstudio and @rootandresin. If you would like further detail about my yoga classes, workshops and retreats, drop a comment.

I will share them regularly in my blast out.

Thank you for providing me with your information. This is not a substitute for medical treatment. All information is kept confidential. Please initial below understanding these terms

Please add your name or intials indicating you understand these terms.