TeleHealing Registration

TeleHealing Registration

For Filipinos residing in the the Philippines
TeleHealing Client Intake Form

CONFIDENTIAL
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

City/District/TownState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Mobile Phone*
Format: (000) 000-0000.
E-mail*
example@example.com
Who recommended you? How did you find out about us?
How can we help you? Please mention any reasons for enrolling into our program.*
Personal Information
Marital Status
No. of children, if any
Employment status
Occupation/Career
Name of employer, if applicable
Tell us about your Overall Health and Habits
TeaCoffeeTobaccoAlcoholPrescription DrugsRecreational Drugs
BeefPorkChickenSeafoodVegetablesDairy ProductsOther
Specify any recreational or prescription drugs you are taking here
How often do you exercise?*
What exercise/s do you do?
What is your weight goal?
My current weight is:
High Blood PressureLow Blood PresureHeart DiseaseAsthmaSpinal IssuesCancerDiabetesAnemiaBleedingInternal OrgansAddictionLearning DisabilitiesEpilepsyVertigoMigraineInfertility/ConceptionPeri-menopauseMenopausePainFatigueOther

Total Health Status - Rate yourself on a scale of 1 to 5 (1 is Poor and 5 is Excellent)*

Rows	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Physical Health
Vitality and Energy Level
Emotional Stability
Mental Attitude and Clarity
Religious/Spiritual/Inner Alignment

General Quality of Life - Rate yourself on a scale of 1 to 5 (1 is Poor and 5 is Excellent)*

Rows	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Relationships at Home
Relationships at Work
Social Relationships
Job/Role Satisfaction
Quality of Rest/Relaxation
Ability to Manage Stress
Quality and Time for Recreation
Financial/Material Life
Level of Success
Level of Self-Fulfillment in Life

Psychological Status*

Rows	Yes	No
Fear/Phobia
Anger/Frustration
Anxiety/Worry
Sadness/Loneliness/Grief
Guilt/Self-Pity
Resentment/Pent-up Emotions
Lack of Self-Confidence/Self-Esteem
Laziness
Lack of Motivation/Purpose
Slowness in Action/Indecisiveness
Psychological Depression
Suicidal Tendency
Self-Destructive Behavior
Anti-Social/Oppositional Tendency
Vice/Addiction
Compulsion/Obsession
Trauma/Post-Traumatic Issues
Shame
Abused/Victim
Abuser

Please describe any other psychological issues you may have or give additional information related to the items you have checked above.
COVID-19 Status
YesNo
If you have tested positive for COVID-19, please provide the following information. Otherwise, you may skip to the next section.
Date of infection/exposure (if known):
Date when symptoms started:
Date of Positive COVID-19 test:
Name of attending physician:
Name of cilnic/hospital of testing or confinement:
Date of related hospitalization if any:
ColdDry coughRunny or stuffy noseMalaise/fatigueFeverBody acheDifficulty breathingBronchitisPneumoniaAcute Respiratory Distress Syndrome (ARDS)NauseaDiarrheaPressure or pain in chestBluish face or lipsLoss of taste/smell
Please upload your recent picture*

Full body picture is preferable
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DISCLAIMER/WAIVER I understand that TeleHealing and World Institute for Incurable Diseases (WIID)TM programs do not claim to supplant or replace medical or psychological treatment. I understand that TeleHealing, WIIDTM Specialists and MDP BElifeTM services do not diagnose any health or psychological conditions. I hereby forever release and hold TeleHealing, World Institute for Incurable Diseases, BElife, Master Del Pe and all of its officers, agents, employees, directors, executives, managers, successors and licensees harmless from any and all liability, encumbrances or responsibility for the outcomes of services provided. Everything I have written and answered is true and correct.
Signature*

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Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date Signed*

MonthDayYear
Date

Payment
Select the number of sessions you are enrolling in:
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Tele-Healing Session
Tele-Healing is a monthly 1.5 hours event with Master Del Pe and his team of international healing specialists. Each session includes bio-mechanical exercises, breathing techniques and an energy healing meditation guided by Master Del Pe to help you boost your vitality, calm your emotions, sharpen your mind and awaken the power of your soul. We help you overcome your life concerns by going beyond the symptomatic issues and addressing the root causes so that you can not only take care of your current problems, but also heal your past, transform your present and empower your future.

$50.00 Quantity

Total

$0.00
How to Pay:

1. Make your payment to:

Bank Name: Bank of the Philippine Islands (BPI)

Account Name: Roshni Ashok

Account Number: 8619-1924-44

Swift Code: BOPIPHMM

2. Email payment confirmation or bank deposit slip to register@masterdelpe.com.

In the subject field, put your name and then 'TeleHealing'.

Example: John Doe, TeleHealing

3. We will inform you if the payment has been received.
Should be Empty:

TeleHealing Registration

TeleHealing Client Intake Form

Personal Information

Tell us about your Overall Health and Habits

COVID-19 Status

Payment