Energy Therapy Intake Form

Address

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

Excellent Very Good Good Fair Poor
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?
Bear Foot Yoga, LLC | 262-767-1111 | bearfootyogastudio.com
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Basic Information