Energy Therapy Intake Form

Energy Therapy Intake Form

Healing Touch, Reiki & Auyrvedic Marma Point Therapy
Basic Information
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Age/DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred by
Questionaire
Prior Energy Therapy and your experience (includes reiki, acupuncture, reflexology, etc.)
Primary reasons for seeking Energy Therapy
How would you rate your current level of stress on a scale of 1-10 (1 low, 10 high)?
Current overall health condition

ExcellentVery GoodGoodFairPoor
Please describe each area as improving, deteriorating or staying the same and any comments.
Home Life
Work Life
Physical Health
Mental / Emotional Health
Spiritual beliefs / practices / affiliations (Is your belief a source of support to you?)
Current self care practices, hobbies and interests
Relevant Health History
Current or chronic medical conditions, diagnosis, surgeries or treatments with dates
Mental health issues or diagnoses
Significant physical or emotional traumas (condition / date / year)
Describe your sleep patterns and do you use sleep aids?
How is your digestion and elimination?
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Basic Information