Shiatsu Questionnaire Name(Required) Date(Required) Address(Required) Phone(Required)Email(Required) Have you ever received shiatsu?(Required) Have you received any other type of massage?(Required)Please specifyHave you had any operations or broken bones(Required)Please explain - past two yearsAre you being treated for any health conditions(Required)Please specifyDo you hold tension in your body(Required)Please specify areas of bodyAre you taking medications(Required)Please specifyWhat do you hope to gain from your shiatsu(Required)Would you like to receive my free e-newsletters, Whole Health Matters and Holistic Weight Loss, with tips and inspirations to help you get healthy and live your best life? Choose one or both. Provide email address if different from one previously given.Would you like to receive my free e-newsletters, Whole Health Matters and Holistic Weight Loss, with tips and inspirations to help you get healthy and live your best life? Choose one or both. Provide email address if different from one previously given. Whole Health Matters Holistic Weight Loss I do not wish to receive either newsletter PrivacyYour information is kept in the strictest confidence and is never shared with anyone. Your answers are encrypted for greater security.