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Sabai Sabai Essential Touch - Intake Form
Client Information
Full Name
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Address
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Street Address Line 2
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E-mail
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Phone Number
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Area Code
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone Number
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Area Code
Phone Number
How did you hear about us?
Medical History
Are you under the care of a qualified healthcare professional? If yes, please state why:
Are you pregnant?
Yes
No
Women only
What medications, supplements and over the counter items do you take regularly or are currently prescribed:
Let's get a current picture of your health
Cardiovascular Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Adrenal Fatigue
Aneurysm
Angina
Arrhythmia
Atherosclerosis
Cardiovascular Challenges
Cholesterol Problems
Coronary Artery Disease
Diabetes
Heart Disease
Heart Failure
High Blood Pressure
Hypertension
Low Blood Pressure
Phlebitis
Raynaud's Disease
Varicose Veins
Cellular Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Addison's Disease
Adrenal Fatigue
Alzheimer's Disease
Anemia
Angelman Syndrome
Anxiety Disorder
Autoimmune Disease
Brain Injury
Cancer
Concussion
Creutzfeldt-Jakob Disease
Cystic Fibrosis
Dementia
Epstein Barr
Fibromyalgia
Grave's Disease
Leukemia
Lupus
Lyme Disease
Lymphoma
Major Depressive Disorder
Malaria
Multiple Myeloma
Multiple Sclerosis
Nephritis
Parasites
Parkinson's Disease
Schizophrenia
Shingles
Sickle-Cell Disease
Spinal Muscular Atrophy
C 2 Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
ALS
Aplastic Anemia
Cancer
Cardiomyopathy
Cardiovascular Disease
Chronic Fatigue
COPD
Cystic Fibrosis
Cystits
Diabetes
Encephalopathy
Endometriosis
Epstein-Barr
Fatty Liver
Gallstones
Glioblastoma
Guillain-Barre Syndrone
Heavy Metal Toxicity
Hemolytic Anemia
High Blood Pressure
High Blood Sugar
High Cholesterol
Hypotension
Hypoxia
IBS
Insulin Resistance Syndrone
Leukemia
Lymphoma
Meningitis
Metabolic Syndrome
Multiple Myeloma
Necrosis
Neuralgia
Neuronal Toxicity
Niemann-Pick Disease
Obesity
Ovarian Cancer
Peripheral Neuropathy
Pneumonia
Polyneuropaty
Proteopathy
Pulmonary Edema
Sarcoma
Shingles
Sickle Sell Disease
Spondylosis
Stroke
Syndrome X
Wilson's Disease
Chi Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Fibromyalgia
Back Pain
Herniated Disc
Neuropathy
Chronic Fatigue
Arthritis
Scoliosis
Aches
Bursitis
Inflammation
Joints
Migraine
Restless Leg Syndrome
Rheumatoid Arthritis
Sciatic
Scleroderma
Autoimmune Disease
Tension
Seizures
Stroke
Musle Weakness
Adrenal Fatigue
Flu/Cold
Bacterial Infections
Gout
Complex Regional Pain Syndrome
Tendonitis
Peripheral Neuropathy
Postherpetic Neuralgia
Digestive Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Acid Reflux
Acidosis
Acne
Allergies
Atopic Dermatitis
Bloating
Candida/Yeast
Celiac Disease
Cellulite
Cholera
Cirrhosis
Colic
Colitis
Constipation
Coronary Artery Disease
Crohn's Disease
Cystitis Dermatitis
Cysts
Diarrhea
Diverticulitis
Eczema
Endometriosis
Energy
Fibroid Cysts
Fibromyalgia
Gastritis
Giardia
Heartburn
Hemorrhoids
Hepatitis
IBS
Immune Support
Indigestion
Inflammation
Kidney Infection
Liver Detox
Lupus
Macular Degeneration
Nausea
Pancreatitis
Psoriasis
Stomach Aches
Ulcers
Urinary Tract Infections
Emobic Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Anger
Anterograde Amnesia
Anxiety
Appetite Dysregulation
Autoimmune Encephalitis
Bipolar Disorder
Depression
Diabetes
Disinhibited Behavior
Emotional Trauma
Epilepsy
Fear
Grave's Disease
Hyperglycemia
Hyperorality
Hypoglycemia
Hypothyroidism
Hypoxia
Insomnia
Kidney Disease
Limbic Encephalitis
Memory Loss
Mental Fatigue
OCD
Panic
PMS
Postpartum Depression
Renal Failure
Stress
Forgiveness Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Abuse
Anger
Anorexia
Anxiety
Apical Ballooning Syndrome
Arrhythmia
Bacterial Infection
Broken Heart Syndrome
Bulimia
Cardiomyopathy
Cirrhosis
Depression
Disdain
Emotional Trauma
Fatigue
Fear
Hate
Hepatitis
Hypertension
Immune Support
Jaundice
Liver Disease
Loneliness
Mental Fatigue
OCD
Pirmary Sclerosing Cholangitis
Post-Traumatic Stress Disorder
Primary Biliary Cholangitis
Rage
Resentment
Respiratory Challenges
Self-Doubt
Self-Hate
Sinus Infection
Stress
Takotsubo
Hormone Balance Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Abdominal Cramps
Addison's Disease
ADHD
Anxiety
Cramps
Cushing's Disease
Depression
Endometriosis
Fibroid Cysts
Grave's Disease
Hashimoto's Disease
Hot Flashes
Hyperthyroidism
Hypoglycemia
Hypopituitarism
Hypothyroidism
Infertility
Insomnia
Menopause
Post-Partum Depression
Premenstrual Syndrome (PMS)
Rosacea
Stress
Thyroid
Infectious Disease Applications (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Bacterial Infections
Candida
Colds
Constipation
Creutzfeldt-Jakob Disease
Croup
Epstein Barr
Flu
Fungus
Hepatitis
Immune Support
Infections
Influenza
Lyme Disease
Malaria
Meningitis
Mono
Parasites
Pneumonia
Shingles
Sore Throat
Staph
Strep
Viral Infections
Yeast Infections
Inflammatory Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Aches
Arrhythmia
Arthritis
Athletes Foot
Back Pain
Bursitis
Chronic Fatigue
Connective Tissue
Constipation
Cramps
Cystitis
Dementia
Energy
Epstein Bar
Exhaustion
Fever
Fibromyalgia
Gout
Headaches
Herniated Disc
Hypertension
Inflammation
Joints
Lupus
Meningitis
Migraine
Muscle Fatigue
Nausea
Neuralgia
Neuritis
Neuropathy
Paget's Disease
Phlebitis
Prostate
Rash
Restless Leg Syndrome
Rheumatoid Arthritis
Sciatica
Scleroderma
Scoliosis
Spondylitis
Tendonitis
Varicose Veins
Lymphatic Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Acidosis
Acne
Allergies
Atopic Dermatitis
Cellulite
Congestion
Cushing's Disease
Cystitis
Dermatitis
Diabetes
Ear Ache
Eczema
Edema
Fibroid Cysts
Fluid Retention
Hearing Challenges
Heart Burn
Immune Support
Infertility
Kidney Stones
Laryngitis
Lymphedema
Neuritis
Obesity
Psoriasis
Raynaud's Disease
Scleroderma
Swollen Lymph Nodes
Tinnitus
Weight Loss
Yeast Infection
Maxim Protocol aka Anti- Cancer Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Addison's Disease
Allergies
Autoimmune Disease
Bacterial Infections
Brain Stem Glioma
Cancer
Cholangiocarcinoma
Cirrhosis
Digestive Issues
Epstein Bar
Influenza
Kidney Infections
Kidney Stones
Leukemia
Liver Challenges
Lupus
Lyme Disease
Lymphoma
Melanoma
Meningitis
Migraine
Mononucleosis
Multiple Myeloma
Osteosarcoma
Parasites
Pneumonia
Shingles
Soft Tissue Sarcoma
Tumor
Uterine Sarcoma
Neurological Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Abuse Trauma
ADHD
Alzheimer's Disease
Aneurysm
Anxiety
Autism
Bell's Palsy
Central Nervous System Stimulant
Concussion
Cushing's Disease
Dementia
Depression
Emotional Trauma
Endocrine Challenges
Epilepsy
Fear
Grave's
Guillain-Barre Syndrome
Headache's
Insomnia
Lou Gehrig's Disease
Macular Degeneration
Memory Loss
Multiple Sclerosis (MS)
Neuritis
Neuropathy
Paraneoplastic Encephalomyelitis
Parkinson's Disease
Polyneuropathy
Post-Traumatic Stress Disorder
Seizures
Strokes
Tension
Osteo Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Achondroplasia
Bone Cancer
Bursitis
Fibrous Dysplasia
Gout
Metabolic Bone Disease
Multiple Myeloma
Neuropathy
Osteoarthritis
Osteomalacia
Osteomyelitis
Osteopenia
Osteoporosis
Osteosarcoma
Paget's Disease
Perthes Disease
Porotic Hyperstosis
Rheumatoid Arthritis
Spondylitis
Varicose Veins
Respiratory Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
ARDS
Asthma
Breathing
Bronchitis
Common Colds
Congestion
COPD
Cough
Croup
Cystic
Emphysema
Fibrosis
Flu
Influenza
Laryngitis
Pneumonia
Pulmonary Edema
Respiratory Issues
Rhinitis
Sinus Infection
Sinusitis
Sore Throat
Strep
Tonsillitis
Tuberculosis
Sensory Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
ADHD
Angelman Syndrome
Anxiousness
Arthritis
Asperger Syndrome
Autism
Autoimmune Disorders
Cerebellar Ataxia
Development Delays
Dyspraxia
Dystonia
Epilepsy
Heart Disease
Huntington's Disease
Hyperesthesia
Hypertension
Kidney Disease
Mood Swings
Multiple Sclerosis
Neurodegenerative Disease
Obsessive Behavior
OCD
Olfactory Processing Disorder
Pervasive Development Disorder
Proprioception
Schizophrenia
Sensory Craving
Stress
Solar Application (Possible Associated Conditions)
No, never
Yes, currently
Not currently, but within the last year
Not currently and longer than 1 year ago
Addison's Disease
Adrenal Fatigue
Adrenal Gland Cancer
Adrenal Incidentaloma
Adrenal Insufficiency
Anorexia
Anxiety
Bipolar Disorder
Chronic Fatigue
Congenital Adrenal Hyperplasia
Depression
Diabetes
Fatigue
High Blood Pressure
Low Blood Pressure
Low Energy
Mental Fatigue
Muscle Weakness
Nausea
Nephritis
Obesity
Osteoporosis
Stress
Weight Loss
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