Healing Lotus Confidential Client Case History and Intake Form

You may copy and paste this form into Word, fill it out and email it to  intake@therapylotus.com or you may print it out and bring it with you to your Reiki appointment.

 

Name: Date:
Address: Phone:
Postal Code: Email:
Date of Birth: Referred by:
Would you like to receive updates via email?

 

Primary Concerns: Level: 1(hardly notice symptoms) to 10 (symptoms are unbearable)

 

Medications/Remedies/Supplements & Reason for taking:
 

 

 

Significant Accidents/Injuries:
 

 

 

Please place an X beside any conditions that apply (past or present):
Cancer Varicose Veins Allergies:
Heart Disease H/L Blood Pressure Surgery:
Diabetes Paralysis Genetic Disorders:
Stroke TMJ Dysfunction Phobias:
Epilepsy Arthritis  

 

Place an X beside any symptoms that you experience:

Headache

Faintness/Dizziness

Tightness in Jaw

Weak body parts

Smoking (#/day__)

Nervousness

Poor Appetite

Excessive Urination

Grinding of Teeth

Heavy feeling in limbs

Blurriness of vision

Constipation

Loose Bowel Movements

Irritated Bowel

Pains in heart/chest

Indigestion

Insomnia

Fatigue

Cold in hands and feet

Lower Back pain

Shoulder/neck pain

Carpel tunnel syndrome

Menstrual Irregularities

Other:

 

Are you pregnant?

Place an X beside any areas below that you would like improvement in:

Negative self-talk, self-sabotage

Belief in ability to achieve goals

Ability to relax

Ability to use dreams as mental tool for problem solving

Eliminate procrastination

Ability to reach ideal weight

Personal magnetism

Strengthen memory/concentration

Breaking old habits

Release negative events

Ability to align body/mind for self-healing

Ability to take action

Increase learning ability

Beneficial, relationships

Prosperity (attract what you choose)

Attitude and skills at work

Self-Esteem

Youthful Vitality

 

Below, please describe what you would like to accomplish with these treatments?

 

 

 

 

 

 

 

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