Healing HeARTS – Client Form


Name:
Address:
City:
State:
Zip:
Phone Number:
Emergency Contact Phone Number:
Email Address:
Age:
Date of Birth:
Are you 18 years or older? Yes
No

If you are under 18 years of age, a parent or guardian must sign here for Consent Authorization:
Gender: Male
Female
Transgender

Marital Status: Single
Engaged
Married
Seperated
Divorced

Referred By:
Religious Preferences:
Ever used Holistic or Metaphysical services before? List them:
Do You Meditate? Once a day
Weekly
Once a month
Never

Current Medical Condition, Problem or Diagnosis:
Date of Diagnosis:
Doctor or Clinic: (Legal Disclaimer- The author/practitioner does not practice medicine. The author/practitioner does not diagnose, nor cure, nor treat disease nor illnesses. Persons requiring medical diagnosis and possible treatment should seek out medical diagnosis, medical monitoring, and take responsibility for what medical actions should be taken if necessary.)

Location:
Related Illness & Dates:
List Current Medications: (Legal Disclaimer- The author/practitioner does not recommend the discontinuance of legal drugs, medication, or controlled substances prescribed or recommended by an appropriately licensed practitioner.)
Alternative Treatments / Therapies:
Any recurring problems in: Head
Back
Neck
Shoulders
Hip
Legs/Feet
Knees
Hands
None

Any other current problems or conditions?
Describe What You Expect From These Sessions:
Any past Mental or Psychological problems? (Legal Disclaimer- The author/practitioner is not a medical doctor nor a licensed physician nor a licensed psychologist or psychotherapist. Persons with psychological or physical illness that require a medical doctor or psychologist or psychotherapist should contact licensed practitioners.) Yes
No

List Diagnosis & Dates:
Any current Mental or Psychological problems? Yes
No

List Diagnosis & Date of Diagnosis:
Doctor or Clinic:
Location:
Any serious or Major disease or Illness in the Past? Yes
No

List Illness/Condition & Date of Diagnosis:
Any major Surgery in the Past? Yes
No

List Type & Date of Surgery:
Do you have Metal Plates or Rods in your body? List Dates & Locations in body:
Any Major Illness, Surgery, or Disease in the Past Year? Yes
No

List Diagnosis & Date of Diagnosis:
MEDICAL HISTORY (Check any that apply): Heart Problems
Circulation Problems
High Blood Pressure
Digestion Problems
Asthma/Emphysema
Other Lung Problems
Sinus Problems
Arthritis / Rheumatism
Migraine Headaches
Tension Headaches
TMJ Problems
Kidney Problems
Bladder Problems
Liver Problems
Nerve Problems
Thyroid Problems
Diabetes or Pancreas Problems
Cancer
Aids or Immune Problems
Food Allergies
Skin Allergies
Other Skin Problems
Back Problems
Neck Problems
Hip / Leg / Feet Problems
Numbness
Dizziness
Nerve Problems
Stomach Problems
Bowel Problems
Fluid Retention Problems
Menstrual Problems
Prostate Problems
Frigidity/Impotence
Recent Pain
Chronic Fatigue
Chronic Pain
Chronic Infections
Recent Pain
Recent Fever
Recent Infections
Other Problems
None

Specify Other Problems if any:
Any Current Exercise Programs (Specify) :
Any Special Dietary Programs? (Specify) :
I am interested in ordering the following services: Aura Cleansing & Chakra Balancing
Serenity Session
Therapeutic Art
Hypnosis
Chakra Cleansing Retreat (24 Hours)
Serenity Session Retreat (24 Hours)

The author/practitioner/student is practicing alternative or healing arts services & is not counseling or practicing medicine. Services are not to diagnosis, used as an alternative to, or substitute for recognized treatment for any diagnosed condition by a Doctor or Psychologist. Our focus is relaxation & stress reduction. While people may claim to receive healing, results vary from person to person & are not Guaranteed. I have read the above, understand and agree to all terms and conditions. (Signature)


Put a website form like this on your site.