Reiki Client Intake

Reiki Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
This is my:*
E-mail*
Emergency Contact*
Phone Number*
Occupation
Medications
Allergies
Are you Allergic or Sensitive to Essential Oils? (please explain)
History of Pathology
1. List Areas of Discomfort or Pain*
2. Describe Onset of Discomfort or Pain*
3. Rate of Pain Today*
4. Frequency - please select the most accurate*

ConstantOff/OnAt RestWith ActivityOther
5. At what time of day is the pain at its worse?*

MorningAfternoonEveningDuring SleepOther
6. Have you ever injured this area before?*
7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
8. List all related treatments received for this injury.
9. Have you ever received Reiki for a specific problem or injury?
Was the treatment used effective?
10. Is there anything that you do that creates, increases or decreases pain? *
11. What are the physical duties required of your occupation?*
12. What activities/hobbies do you enjoy?*
13. Please list exercise and stress reduction activities (including frequency).*
14. In what position do you most often wake up?*

BackSideStomachOther
15. Are you currently seeing any other healthcare professional?
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Emotional

DepressionAnxietyOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Reiki Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will be fully clothed throughout your session

       • You will have a consultation with your practitioner to discuss your session

       • I understand that my Reiki Practitioner or I may end the session at any time for any reason



Client Agreement:

I understand that Reiki Practitioners do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that Reiki is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive Reiki as a form of therapy.

I understand that the session given is designed to enhance treatments already received by my medical professional; and to bring ease in my stress levels.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my Reiki Practitioner so they adjust.

I have stated my pertinent medical conditions, and will update the Reiki Practitioner of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Natural Health Solutions & Reiki, and my Reiki Practitioner from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

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