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 Have you experienced any vocal trauma or other trauma that you are willing to share about? You are also welcome to tell me briefly in person instead if you are comfortable sharing. * Is there anything else that you think I should know about your health or personal history before we start training together? 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!
