Shiatsu practice - treatment form

Date treatment:

Name: Birthday: Age:

Married: Children:

Profession:

Medication:

Side-effects:

Particulars:

BO-SHIN

position - head/eyes/cheeks/etc. - shoulders/arms/hands - body - legs/feet - colour - tongue

MON-SHIN/BUN-SHIN

voice/breathing/story/element-emotion/history

Dutch School for Classical Shiatsu Page:

SETSU-SHIN

Street:

Postal code:

Place:

Practitioner: Signature client:

touch, diagnosis/abdomen/manipulations/meridians/treatments

Shiatsu practice - after treatment

Date treatment:

Name:

BO-SHINposition - head/eyes/cheeks/etc. - shoulders/arms/hands - body - legs/feet - colour - tongue

MON-SHIN/BUN-SHIN

voice/breathing/story/element-emotion/history

Dutch School for Classical Shiatsu Page:

SETSU-SHIN

Practitioner: Signature client:

touch, diagnosis/abdomen/manipulations/meridians/treatments