Health Questionnaire & Consent Form

The Health Questionnaire and Consent Form

Please answer all of the questions as accurately as you can.

Private and Confidential
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Place and Time of Birth (if known)

PlaceTime
E-mail Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country
Telephone Number
Gender (Biological)

FemaleMale
Hight and Weight

Example: 5''7 or 170 cmExample: 135 lbs or 61 kg
What are the major stressors in your life
Please list the top primary current health conditions
1. Condition (duration)
2. Condition (duration)
3. Condition (duration)
4. Condition (duration)
5. Condition (duration)
Do you have any other health symptoms, please describe:

Severity 1-10 (10 being severe)
1. Symptom (severity)
2. Symptom (severity)
3. Symptom (severity)
4. Symptom (severity)
5. Symptom (severity)
What is your typical Diet

Standard American DietPaleoVeganVegetarianKetogenicLow caloriesRaw foodCarnivoreOther
Do you eat mostly organic produce?

NoAbout 20% of my food is organicMore then 60% of my food is organically grown
Please note below all food sensitivities or/and allergies if you have them:
Do you consume alcohol?

NoYes, 1-2 drinks/weekYes, 4-5 drinks/week or more
Do you tend to be sensitive to supplements, drugs, chemicals, and odors/perfumes?

YesNoOther
How often do you exersise?

I just don't have time1-2 times per week3-4 times per week5-6 times per weekeveryday
If you exercise, please note here what kind of exercise you do :
What medication (drugs) are you currently taking prescribed by a medical doctor (include contraceptive medication)? (state daily dosage & duration)
1. Medication (dosage & duration)
2. Medication (dosage & duration)
3. Medication (dosage & duration)
4. Medication (dosage & duration)
Please list any supplements you currently take (Name, Brand, and Dosage)
1. Supplement Name, Brand, Dosage & Duration
2. Supplement Name, Brand, Dosage & Duration
3. Supplement Name, Brand, Dosage & Duration
4. Supplement Name, Brand, Dosage & Duration
5. Supplement Name, Brand, Dosage & Duration
6. Supplement Name, Brand, Dosage & Duration
7. Supplement Name, Brand, Dosage & Duration
8. Supplement Name, Brand, Dosage & Duration
9. Supplement Name, Brand, Dosage & Duration
10. Supplement Name, Brand, Dosage & Duration
Please note below any additional prescribed Medications or/and Supplements that you are taking:
Please list any additional Health related questions you have here. We will address these during the consultation.
Rescheduling procedures: If you need to reschedule, please do so at least 24 hours before the scheduled session to avoid being charged for that appointment time. The email confirmation you receive right after booking the session provides a link where you can schedule/reschedule.

Cancellation procedures: If you decide to cancel the session (and not reschedule), please do so at least 7 days before the scheduled session for a refund, less the non-refundable credit card fees (approximately 5%). The email confirmation you receive right after booking the session provides a link to cancel the appointment.

Failure to comply with these rescheduling and cancellation policies will likely result in being charged for the session.

I hereby confirm that I have read and agree to the rescheduling and cancellation policies and that all the information I provided on this form is correct to the best of my knowledge. I understand that any information shared in the Intuitive Health Reading or 1:1 session should not be construed as medical advice, professional mental health advice, or any mental health diagnosis, nor is this information a substitute for professional medical or mental health expertise or treatment.
I hereby confirm that this information is correct to the best of my knowledge and that I am not withholding any important information. I understand that neither nutritional, bioenergetic or psychology advice is intended to replace the advice of medical doctors. Nutritional nor bionenergetic medicine does not diagnose or treat any disease state, nor is it a substitute for the medical treatment of a doctor but it can complement it. If you have a health concern always contact your licensed medical practitioner first.
Date

MonthDayYear
Date
Signed

Clear
Should be Empty: