Intake Form

First Name

Last Name

Date

Email

Phone

Address

City

State

Zip Code

Occupation

Sex SexMaleFemale

Date of Birth

Contact Lenses Contact Lenses Yes No

Hearing Aid Hearing Aid Yes No

Are you pregnant? Are you pregnant? Yes No

If so, what month?

Dentures Dentures Yes No

Occupational Stress Level Occupational Stress Level1 Relaxed2345 Not bad/Not great678910 Overwhelmed

Emotional Stress Level Emotional Stress Level1 Relaxed2345 Not bad/Not great678910 Overwhelmed

Relaxation Strategies

Exercise Strategies

Previous Holistic Therapies

Were these successful? Were these successful? Yes No

What hasn't worked for you?

Have you had energy work? Have you had energy work? Yes No

Are you under a Dr's care? Are you under a Dr's care? Yes No

If under Dr's care, for what?

Please, list all medications

Surgeries or injuries

Significant health concerns

Primary current complaint

Additional concerns

Physician's Name

Physician's Phone Number

Cancellation Policy: It is my goal to keep our scheduling as fluid as possible. I understand that life happens to all of us and there may be a need to cancel or reschedule an appointment on short notice. I strive to be as flexible as possible regarding this. However, if short notice cancellations seem to be an ongoing occurrence, I reserve the right to charge a cancellation fee.

I agree to cancellation policy I agree to cancellation policy Yes

Late Policy: If it appears that you are running late for your appointment, please contact me via text at 407-761-8555 as soon as possible to let me know your estimated time of arrival. If my schedule allows me to accommodate your full appointment time I will. However, if it is necessary for us to cut your appointment short, I reserve the right to charge the full amount.

I agree to late policy I agree to late policy Yes