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Alluvial Spa & Massage

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HEALTH HISTORY

FIRST VISIT ONLY

Please fill out the following form to help us understand your personal health challenges.

This information is confidential

Name, Address, Emergency contact info

Main concerns today

Email Address & Phone

Date of Birth

Do you have any Covid 19 symptoms or exposure in the past week? *

No

Yes

Have you been hospitalized in the last 12 months? *

No

Yes

Past or present HEALTH CONCERNS, please elaborate (example-high blood pressure, diabetes, fractures, migranes, pregnancies, allergies, stroke, arthritis, loss of sensation, MS, hardwear) Please included current MEDICATIONS/SUPPLIMENTS

Sign Here

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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