3S Therapeutic Registration Form

3S Therapeutic Registration

Form - Therapeutic Registration

Registration Date





Personal Information

Name
Profession


Email
Cell number







Physical Measurements

Choose your body typeSlimMediumObese

Weight (kg)
Height (cms)
Waist (cms)






Person to contact in Emergency

Contact Persons Relationship
Contact Name
Contact Phone






Normal choice of Food/Drinks

Select your personal preferences with regards to food and drinks

I like SpicyI like Sweet


I prefer Warm foodI prefer Cold food


I prefer Warm/Hot drinksI prefer Cold drinks


I eat Freshly prepared foodI eat Refrigerated/Frozen/Canned food


I eat lots of Vegetables and fruitsI eat more Meat in my diet


I eat at Irregular timesI eat at Regular times



Normal choice of Shower

I like Hot waterI like Cold water


I like to shower in MorningI like to shower in Evening



Normal choice of Exercise

IrregularRegular


I exercise in Cool/Shaded spaceI exercise in Warm/Sunny space




Stress factors in my life
WorkFamilyRelationship

Satisfaction Rate


On the scale of 10 = Most satisfied to 1 = Least satisfied, I would rate the satisfaction in the various aspects of my life as follows:
Work/Life's purpose 0
Creativity 0
Environment 0
Relationships 0
Money 0
Sexuality 0
Mental health 0
Physical health0
Spirituality0

General Health Information
Are you currently experiencing pain or other symptoms such as lack of sleep, inability to perform tasks etc due to pain?
Briefly rate and describe your pain or other symptoms?

Are you currently on any medication? If so, please indicate for what condition and duration? Please describe any known side effects of these medications (such as change in heart rate,nervousness,lack of coordination,etc.) that may impact your practice
My major health issues are approximately since :


Special Remarks regarding my health and wellness


I have read and agree with the terms and conditions