Health questionary

Health questionnary

We will advice you the therapy to book according to your answers.

Mitaka: Sun, Mon, Tue, (Wed)・Thu: OFF・Uenohara/Yoyogi: on request
Heart, breathing issue, operation, fracture, twisted anckle, pathology, psychiatry
Recurring pains, loss of a relative, major event or trauma, sensitive subject
If uncomfortable, please details below.
If uncomfortable, please details below.

Thanks for filling the form, we will get back to you soon.

*Any informations share here are confidential and will stay between you and your body mind therapist.

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