Which treatment/treatments are you interested in?
Usui Reiki
Sekhem Reiki
Pellowah Healing
Pellowah Practitioner Attunement
Kinetic Shift
Indian Head Massage
Meditation/Mindfulness Session
Holistic Soul Journey Session
Pellowah Workshop
Holistic Soul Journey Workshop
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
Age
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Next of kin and number
Date of First Session
/
Day
/
Month
Year
Date
Medical history
Allergies
Any health concerns, general state of health
Are you taking any current medications/supplements?
Why would you like to receive a treatment? What would you like a treatment to help you with?
Do you smoke?
How many?
Do you drink alcohol?
How much?
Do you eat healthy?
Any problems with diet and digestion?
Amount and quality of sleep?
Do you wake up rested?
Energy levels on the scale of 1-10
Are you working?
Do you like your job?
Any spine or structural issues?
Can you lie on your back?
Do you exercise regularly?
Anything else I need to know?
Any questions you need to ask?
Are you pregnant? If yes how many weeks/months?
Enquiries/Feedback
*
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