Energy Healing Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Language
*
Please Select
English
Spanish
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Prefer not to answer
What is the activity level at your job?
*
None
1
2
3
4
High
5
1 is None, 5 is High
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Wellness Intake
Nutrition
Do you follow a specific eating style or diet?
*
Yes
No
If so, please state what and since when?
What is your typical breakfast?
*
Do you eat leafy greens on a daily basis?
*
Never
Rarely
Occasionally
Always
In the last 3 years, how many courses of antibiotics have you been on?
*
On average, how many fruit juices or fizzy drinks do you have a week?
*
How many caffeinated beverages do you consume in a day?
*
Do you have one within the first hour of waking up?
Yes
No
How many teaspoons of sugar do you have in your tea or coffee?
How many alcoholic beverages do you consume per week?
*
Do you snack through the day?
*
Yes
No
If yes, what kind of snacks?
How often do you make an eating decision you regret?
*
Never
1
2
3
4
Very Often
5
1 is Never, 5 is Very Often
Around what time do you stop eating in the evening?
*
7-8 pm
8-9pm
9-10pm
10-11pm
11pm or later
Do you take any supplements or vitamins?
*
Yes
No
If yes, please list all and frequency.
On average, how many cups of water do you drink a day?
*
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Wellness Intake
Sleep
On average, how many hours of sleep do you get a night?
*
10-11
8-9
6-7
Less than 5
How long does it usually take to fall asleep once in bed?
*
Asleep instantly
About an hour
Several hours
All night long
If you have any diagnosed health problems that result in problems sleeping, please list the condition(s) below.
Do you tend to have issues staying asleep through the night?
*
Never
Rarely
Sometimes
Often
Very Often
What time do you usually fall asleep?
*
Earlier than 8 pm
8-10 pm
10-12 pm
1-2 am
After 2 am
Does this vary over the weekend?
*
Yes
No
On average, how many nights a week do you have trouble sleeping?
Never
Once or twice
Several times
Always
How would you rate your sleep quality?
*
Awful
1
2
3
4
Excellent
5
1 is Awful, 5 is Excellent
How would you rate your energy levels when you wake up?
*
No Energy
1
2
3
4
Overly Energetic
5
1 is No Energy, 5 is Overly Energetic
How many times do you snooze your alarm in the morning?
*
O
1
2
3+
Do you use any electronic devices whilst in bed?
*
Never
Rarely
Sometimes
Always
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Wellness Intake
Stress Levels
What would you rate your general anxiety level?
*
Always Anxious
1
2
3
4
5
6
7
8
9
Never Anxious
10
1 is Always Anxious, 10 is Never Anxious
How stressful do you consider your job?
*
Not stressful
Slightly stressful
Stressful
Very stressful
Are there any notable things that cause you stress?
Do you have any coping strategies to distract or conceal anxiety or stress?
*
Yes
No
If yes, through what means?
Do you watch, listen to, or read the news on a daily basis?
*
Yes
No
When was the last time you cleaned your home/living space?
*
This week
Last week
Last month
Hardly ever
On average, how much time do you spend on social media?
Never on social media
1-3 hours
4-8 hours
Always on social media
How often do you feel negative emotions arise out of nowhere?
*
Never
1
2
3
4
Very Often
5
1 is Never, 5 is Very Often
Do you have any habits you would like to cut out of your life?
Yes
No
If so, list below.
Do you have any habits you would like to add to your life?
*
Yes
No
If so, list below.
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Wellness Intake
General Health
How many times a week do you exercise or move with intensity?
*
Never
1-3 times
4-6 times
7+ times
Which kind(s) of exercise or movement do you do, how long, and how frequently?
Are you a current smoker or vaper?
*
Yes
No
If so, how often do you smoke or vape a week?
Once or twice
A couple of days
Every other day
Every day
List any injuries, new or old, below.
List any medications you are currently taking below.
How much time would you be willing to allocate to a morning routine?
*
No time
10 minutes
30 minutes
An hour or more
How much time would you be willing to allocate to an evening routine?
*
No time
10 minutes
30 minutes
An hour or more
How ready are you for a change?
*
Not At All
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not At All, 10 is Extremely
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