If you are unable to send message from below form,

    Click here to send Email

    3S Therapeutic Registration

    Form - Therapeutic Registration

    Registration Date

    Personal Information

    Name

    Profession

    Email

    Cell number

    Physical Measurements

    Choose your body type

    SlimMediumObese

    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 [starratingawesome starrating-110 min:1 max:10 icon_class:fa-heart show_number]
    Creativity [starratingawesome starrating-111 min:1 max:10 icon_class:fa-heart show_number]
    Environment [starratingawesome starrating-112 min:1 max:10 icon_class:fa-heart show_number]
    Relationships [starratingawesome starrating-113 min:1 max:10 icon_class:fa-heart show_number]
    Money [starratingawesome starrating-114 min:1 max:10 icon_class:fa-heart show_number]
    Sexuality [starratingawesome starrating-115 min:1 max:10 icon_class:fa-heart show_number]
    Mental health [starratingawesome starrating-116 min:1 max:10 icon_class:fa-heart show_number]
    Physical health[starratingawesome starrating-117 min:1 max:10 icon_class:fa-heart show_number]
    Spirituality[starratingawesome starrating-118 min:1 max:10 icon_class:fa-heart show_number]

    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

    Related Images: