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My Story Therapy Services Shiatsu Massage Ear Acupuncture Baby Shiatsu Massage West Cork Shiatsu Massage For Kids And Teens Corporate Wellness Service Connect

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Take Our Health Questionnaire

Online Wellness Health Questionnaire

Name *

First Name

Last Name

Company Working For *

Email *

Date of Birth

Please detail your medical history in the last 12 months (any operations, illnesses, injuries etc.) Your answer

Are you currently receiving treatment from a GP/health professional? * *

If yes to the above, please give details:

Do you currently have any of the following conditions?

Anxiety

High/Low Blood pressure

Neck/Shoulder problems

Back problems

Stress

Headaches/Migraines

Hip problems

Low mood

Low energy

Sleep difficulties

Knees/ Ankle problems

Other

Could you be pregnant?

Please indicate your consultation preference:

Dynamic & Physical

Relaxing & Meditative

Combination of both

Movement & Meditation

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