Footzoning Intake

Basic Info

Today's Date

YYYY

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Occupation

If you are not technically "working" for yourself or someone else, please give a short explanation of what you spend your time doing.

History

Have you been foot zoned before?

If yes, how many footzones have you had in the past 2 years?

Medical conditions or concerns?

Please include any official diagnoses and/or general concerns even if they have not been diagnosed.

Conditions for which medication has been prescribed:

Please list any surgeries or implants including pacemakers, screws, metal plates, or IUDs & corresponding dates if possible.

What is your greatest hope for what we can accomplish with footzoning at your appointment?

Have you read and do you agree to the terms in the disclaimer? (https://www.khailoh.com/disclaimerfootzoning)

If you answered yes, and you are choosing into this experience with me, please type your name here indicating your signature.