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Energy work Intake
Please fill out before your session.
Name
Age
Gender
Email
Phone Number
Occupation
Please list any pre-existing medical conditions (e.g. diabetes, heart disease, etc.).
Please list any pre-existing medical conditions (e.g. diabetes, heart disease, etc.).
Please list any allergies or sensitivies.
Please list any previous surgeries or procedures.
Please detail any chronic pain or discomfort.
Please list any diagnosed mental health conditions.
Please include any other health history not described above.
How would you rate your overall well-being on a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
Do you experience any specific energy imbalances or blockages? If yes, please describe.
Have you ever received any energy work or holistic therapies before? If yes, please provide details.
Are there any specific areas of concern you would like to address through energy work?
Please describe your current diet and eating habits.
How often do you exercise or engage in physical activities?
Do you have any sleep-related issues or disorders?
Are you involved in any spiritual or mindfulness practices? If yes, please explain.
What are your primary goals for energy work and holistic healthcare?
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