Patient Follow Up

This form is only for people who have had one or more treatments at Vida Lotus. If you have never had a treatment at Vida Lotus, please switch to this new patient form .

Full Name *

Cell Phone Number *

E-mail Address *

Current or Recent Health Concerns:

MigrainesHeadachesNeck painChest painShoulder PainMid back painLower back painPain in the buttocksArm or elbow painPain in the wrists or handsLeg or knee painPain in the ankles or feetMenstrual painStomach acid, gastritis, refluxAllergiesAsthmaFatigueDepressionDiabetesDiminished libidoDry skinEpilepsy, convulsionsFears , phobiasHatredHypertension (high blood pressure)InfertilityInsomniaIrritability: getting upset easily (whether or not it shows)Menstrual irregularityNausea or vertigoNegativityObesityPoor circulationSadness (without justificacion)Skin inflammation, acne, dermatitis, rosaceaStress or anxietyTremors in the handsOther (please specify later)

Other conditions:

Details about the frequency and/or severity of the above conditions

How have you felt since your last treatment at Vida Lotus? (Describe in detail any worsening or improvement in your condition.)

Enviar