Need Help? Call: 248 434-3374

Custom Body Wellness Intake revised 06/21

Personal Info
Contact Info
Other
Medical Info
Conditions
Treatment Goals
Area of Complaint
Massage Goals
Feet
TMJ (Jaw)
Energy
Emotion / Memory
Infectious
Brain Disorders
Oncology
Headaches
Skin
Respiratory
Neurological
Musculoskeletal
Gastrointestinal
Cardiovascular
Kidney
Endocrine
Hearing
Reproductive
Female Health
Prenatal (check boxes to enter details below)
Eating Habits
Accident Info
Which best describes what you are experiencing
Allergy
Emotion / Mood