Microsoft word - nrg4u intake_form.doc

www.Nrg4U.org
CLIENT INTAKE FORM
Please update me on any changes in your contact information!

Date: ____________________
Name: ___________________________________
Address: __________________________________________________________
City:______________________________ State: ________ Zip: ______________
Birth Date: ____________ Current Age ____ Social Security #: _____________________
Occupation: _______________________________________________________
Referred by: ______________________________________________________

Contact information
Home phone: ____________________ Work phone: ____________________
Cell phone: ____________________ email: _______________________________
Please check the box if confidential messages may be left at any of these contact points.
Please circle your preferred contact method.

EMERGENCY CONTACT
Name: ______________________________________________________________
Phone(s): __________________________________________________________
Relationship: _________________________________
Please list the name and specialties of other health care professionals you are currently seeing, as
well as the name of your primary physician and approximate date of your last physical exam:
PLEASE READ CAREFULLY
I understand that the energy medicine sessions I receive are provided for the basic purpose of harmonizing my body’s energies. If I experience any pain or discomfort during a session, I will immediately inform my practitioner. I further understand that energy medicine should not be construed as a substitute for needed medical attention. Energy medicine practitioners do not diagnose, treat, or prescribe for medical conditions. Energy medicine brings about physical improvements by impacting the electromagnetic fields that regulate the body as well as by shifting the more subtle energies described in other cultures with terms such as chakras, meridians, and etheric fields.

Signature: _______________________________ Date: ___________________
What do you hope to gain from your energy medicine sessions?
Describe problems you wish to address. Include how long you have had them, any medical or
psychological diagnosis for them, treatments you have tried, and their effectiveness:
Do you have a Pacemaker? ____
Do you have Metal Plates or Screws in your body? ____
Do you have Diabetes? ____
Are you pregnant? ____

FAMILY MEDICAL HISTORY (please circle all that apply)
Diabetes
Other Significant Illnesses (please list): YOUR MEDICAL HISTORY (please circle all that apply)
Diabetes
Mental Illness Other Significant Illnesses (please list):
Briefly describe any major accidents or traumatic events and approximate dates:
ALLERGIES (drugs, chemicals, foods, airborne allergies, etc.)
How much plain water do you drink per day ? ______________________ Water source? (Please circle) Tap, Filtered (Type of filter__________), Well, Spring, Distilled, Current prescription medications/hormones

Current nutritional and herbal supplements (use back if necessary)
What food(s) do you crave? __________________________________________________________ All answers on this form are confidential. However; if substance-use appears to be life threatening, I am required by law to report it. PLEASE CIRCLE ALL
FREQUENCY
LAST USED
AMOUNT USED
ANY ADVERSE REACTION
THAT APPLY
PER DAY/PER WEEK
MARIJUANA
AMPHETAMINES
What gives you joy? What is your biggest stress? How do you deal with stress? Where does your body hold stress? How do you relax? How do you take care of your body? Are there any other issues you would like to discuss?

Source: http://www.thefourthcoin.biz/nrg4u/downloads/Nrg4U%20Intake_Form.pdf