Name * First Name Last Name Email * Phone (###) ### #### What is your #1 goal for singing? * Where are you mentally with your goals? * Health History Please include injuries as far back as you can remember, nothing is too small! Have you broken any bones? * If yes, please state whether right or left side of your body and the area of your body. Have you had any fractures? * If yes, please state whether right or left side of your body and the area of your body. Have you had any tears or sprains? * If yes, please state whether right or left side of your body and the area of your body. Have you had any head trauma? * If so, please describe the instance(s). Have you been in any car accidents? * If so, please describe the severity and the injuries associated. Do you have any tattoos? * If so, please describe the location(s) on your body. Do you have any piercings? * If so, please describe the location(s) on your body. Do you have any autoimmune issues? * If so, please describe. Do you have any gastro intestinal issues? * If so, please describe. Surgery History * Any scars? Punctures? Dental Work? No surgery history Please list surgery history if applicable. Have you given birth? * Yes Yes, with emergency c-section Yes, with planned c-section No Do you have any EENT issues? * Eyes Ears (Infections, hearing loss) Nose Throat N/A Please describe any EENT issues, if applicable. Does everything do what you ask it to do? * I.e. if you want to move your right foot in a circle, does it do so easily? Yes No If no, please explain. How would you describe your mental health? * Do you have asthma? * Yes No Circulation * Do you have: Cold Hands? Cold Feet? Both? Neither. Blood Pressure * Do you have: High Blood Pressure Low Blood Pressure N/A Do you have acid reflux? * Yes No Is there any other trauma, depression, anxiety, etc. that you are willing to share? * Is there anything else that you think I should know about your health or personal history before we can start assessments? Thank you for your submission! I will be in touch shortly with how we can proceed. Health History I can’t wait to work with you!
