Angels Guided Healing with Aura D'Amato

Angel Communicator, Author, Certified Reflexologist, Energy Healing Practitioner


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

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


 Name: ___________________________________________________________
City:___________________________________________ State:_________________

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


 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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