Floatation Fibromyalgia Project Client History Form

Fibromyalgia Float Form

Please fill out the form below to continue the registration process for the Fibromyalgia Floatation Project.

* Indicates required field

Name *

First

Last

Do you have any health conditions and, if so, how are you managing them? (Chiropractic, physiotherapy, psychiartrist etc.) *

Date of Birth *

Are you taking any medication, and if so, have you experienced any side effects? *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Do you sudder from any symptoms of stress and tell us where you 'carry' your tension in your body. Do you have pain anywhere in your body from injury or strain? *

Do you have any allergies or sensitvities to the following? *

Chlorine Bromine Essential Oils

Phone Number *

So you suffer from ear infections / grommets? *

Yes No

Email *

Are you currently pregnant? *

Yes No

Have you floated in a floatation tank before? *

Yes No

Do you play sport ot are you involved in any other physical activity? If so, what? *

If yes, please indicate where you have floated and how much experience you have had: *

Are you a member of any health/sport/fitness clubs? If so, please specify *

What do you hope to get out of your floating experience and fo you have a specific focus we may be able to assist you with? i.e pain management, relaxation etc. *

Select One *

If 'other', please specify *

Submit

Fibromyalgia Float Form

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