Angels Guided Healing with Aura D'Amato

Angel Communicator, Author, Certified Reflexologist, Energy Healing Practitioner

CLIENT APPOINTMENT FORM

Please print and bring this completed form with you to your appointment
PLEASE PRINT CLEARLY

Aura D'Amato
 Certified Reflexologist & Energy Healing Practitioner
Graduate of NJ Institute of Reflexology 
Member of The  American Reflexology Associations
Member of the Associated Bodywork & Massage Professionals
Holmdel Acupuncture & Natural Medicine Center
732-224-8441    732-888-4910


Date:_______________________________________

 Name: ___________________________________________________________
Address:______________________________________________________________
City:___________________________________________ State:_________________

ZipCode________________________________
 HomePhone:______________________________________________________
Cell Phone_________________________________________________________
Work  Phone ______________________________________________________
EMAIL Address_________________________________________________________ Occupation:__________________________Work Phone:_____________________________ Email:______________________________________________________________________
Referred By:_________________________________________________________________
DOB:____________________________________Are you  pregnant________________________ 
Emergency Contact 
Name:___________________________________________________________

Number:__________________________________________________________

 Are you currently under a Doctorʼs care?_____If yes, what for?__________________ ______________________________________________________________________

 Are you currently taking medication?_____If yes, what?_____________________________________________________________________

Physicianʼs Name and Phone Number:_______________________________________
 
Chiropractorʼs Name and Phone Number:_____________________________________

Have you ever received reflexology?_____If yes, when ___________________________________________________________________ 

Any other holistic or physical therapy?_____If yes, what type?________________________________________________________________________________________

Please check any of the following that apply (past or present)

_asthma  __fibromyalgia    __lupus__allergies  __frequent urination    __lyme’s disease

__anxiety  __feeling cold    __menstrual disorders__AIDS/HIV  __feeling hot    __neck pain
__arthritis  __foot pain    __numbness & tingling__back pain  __gastrointestinal disorder    __night sweats

__blurred vision  __gout    __palpitation (heart)__breathing difficulties  __glaucoma   
__poor appetite
_cancer  __hepatitis    __poor coordination__carpal tunnel syndrome  __hot flashes    __persistent cough__chest pain (or tightness)  __headache    __restlessness

__chronic fatigue  __heart problems    __shoulder pain__constipation  __hives    __spinal misalignment

__depression  __high blood pressure    __spinal fusion__diabetes  __irritable bowel syndrome   
__skin problem
__diarrhea  __immune deficiency    __sport injury__difficult concentrating  __itchiness    __sciatica__digestion problems  __insomnia    __stress__dizziness/ light headedness  __lack of clarity    __tendonitis_other (please specify)      __migraine headache   _low blood pressure___foot fungus                           ___varicose veins___stomach concerns    ___fatigue  ____swelling or edema _____numbness or tingling

Other Concerns (please explain)__________________________________________
 ____________________________________________________________________
 ______________________________________________________________________

Have you suffered any illness, undergone any surgery (major or minor), or suffered any acute
injuries in the past 6 months? If yes, please explain:_____________________________________________________________________________________________________________________________________________________________

 Please share your main concerns for coming today______________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Please Read the Following Information Carefully and Sign Where Indicated

I, (print name) ______________________________________ understand that the reflexology I receive is provided for the basic purpose of relaxation, stress reduction, and relief of tension. If I experience any pain or discomfort during this or any subsequent session, I will immediately inform the practitioner so that the pressure may adjusted accordingly.
I further understand that reflexology is not to be construed as a substitute for medical attention, examination, diagnosis, or treatment and that I should seek the advice of a physician, chiropractor, or any other qualified medical specialist of any physical or mental condition I may have.
I have been made aware that under certain medical conditions, reflexology is contraindicated (should not be performed). I affirm that I have stated all known medical conditions and have updated the practitioner as to any changes in my medical profile. I agree to keep the practitioner updated regarding my medical profile and I affirm that there shall be no liability on the practitionerʼs behalf should I forget to do so. All statements I have made herein are true and accurate to the best of my knowledge.

Signature:______________________________________ Date:__________________

 
 
 
 
 
 
Associated Bodywork & Massage Professionals
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