ReVitalizeLife Intake forms

Name *

First

Last

Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone 905-555-5555 *

Mobile 647-555-5555 *

May we send you appointment reminders to you by text? *

Yes No

Date of Birth (MM/DD/YY) *

Age *

Occupation *

Name *

Relation *

Phone Number *

How did you hear about Elvira?

comment *

Referred by: *

Name *

Practitioner: *

Phone Number *

Name *

Practitioner: *

Phone Number *

Name *

Practitioner: *

Phone Number *

Comment *

LIST OTHER HEALTH CONCERNS AND SYMPTOMS IN ORDER OF IMPORTANCE TO YOU BELOW: *

Describe your present general state of health: *

Please indicate any serious conditions, illnesses, infections, injuries, and any surgeries or hospitalizations (provide approximate dates): *

List any allergies (medicines, environmental, food, etc.) you have: *

Medication *

Dose (i.e. mg) *

Taken Since (How Long) *

Comments/Other Medications/Adverse Reactions *

How many times have you been treated with antibiotics? *

Number of steroid type drugs used during the last year: *

Number of root canals: *

List all over the counter medication that you take (e.g. Aspirin, Tylenol, Tums, etc.). Include dosage and frequency and any adverse reactions/allergies to medications: *

List all vitamins, minerals, botanical (herbal) medicines, Asian medicines (Chinese Patent drugs), or homeopathic remedies that you are currently taking. Indicate daily dosage: *

Do you use any recreational drugs? Y/N (If yes, indicate what type and frequency of usage): *

Mothers's Side *

Father's Side *

Siblings *

What foods do you consume on a daily basis? *

Beverages *

Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)? *

YES NO

If yes, please describe *

Number of glasses of water, herbal tea, or natural fruit juice per day: *

Do you drink alcohol? *

YES NO

(If yes, indicate what type of alcohol and how many glasses per week): *

Do you smoke? *

YES NO

(If yes, indicate for how long, and how many cigarettes/cigars per day): *

Do you drink caffeinated beverages? *

YES NO

(If yes, indicate what type and how much per day): *

On average, how many hours of sleep do you get per night? *

On average, how many hours do you work each day? *

What level of personal stress have you been experiencing within the last 2 weeks? *

0 1 2 (minimal) 3 4 5 (average) 6 7 8 (considerable) 9 10 (unbearable)

Do you exercise? *

YES NO

(Indicate what type of exercise, how long, how often): *

Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe (examples - mold, radiation, smoke): *

How stressful is your work, or other aspects of your life? How well do you handle these stresses? *

How would you describe the emotional climate of your home? *

other *

Is there anything that you feel is important that has not been covered? *

I, (print full name) *

understand that the Intuitive Energy Reading and Healing session provided by Elvira Gesummaria, is intended to enhance relaxation, increase communication within areas of the body and to educate me to possible energetic or emotional blocks that may create pain and disease. • Intuitive Energy Healing includes various forms of Energy Medicine and Spiritual Healing which are non-invasive, safe, and objective. They utilize the body’s own innate intelligence to re-establish communication within itself. • I understand that Intuitive Readings and Healings are not a substitute for medical diagnosis, treatment or medications. • I am aware that the practitioner does not diagnose illness or disease, nor does the practitioner prescribe medications. • I understand that participation in a session is voluntary and that at all times I may choose to end my participation. • In addition, certain sessions entail light tapping and touching of energy points on the body. The practitioner will inform me where tapping and/or touching by the practitioner and/or myself will occur, thus allowing for my ongoing consent. • I understand that information exchanged during any session is educational in nature and is used at my own discretion, and Elvira will not be held under any legal responsibility or obligation for decisions made by you, the client, as a result of receiving an intuitive reading or healing.. • I also understand that any information imparted during sessions is confidential and will not be released without my prior consent, except as required by law. • I understand that by providing this informed consent I am assuming full responsibility for my healing session and I hold harmless the practitioner Elvira Gesummaria. Payments and Rates: • I understand that payment is due before my appointment by e-transfer, credit card, or paypal. • I understand that packages must be paid in full before first appointment. • I am aware of session costs (in CAD): $140/hour (pay as you go) Package of 4: $500 ; Package of 8: $900 Animal Session: $140/hour (pay as you go) I understand that packages are to be used within 6 months of purchase date. • Since time has been especially reserved for me, I understand that a 24 hour cancellation notice is expected and missed appointments will be charged. • If I have any questions or concerns, I will address these promptly with the practitioner. I hereby authorize, Elvira Gesummaria to provide me with Intuitive Energy Reading and Healing sessions and by signing below I agree to all the terms above. **Client Signature (Full Name) *

HEALTH INTAKE FORM

health intake form - Intuitive Energy Healing (Video Call)

Emergency Contact:

How did you hear about Elvira?

Names of other health care practitioners (medical doctor, chiropractor, specialist, physiotherapist, etc.) you are seeing:

CHIEF HEALTH CONCERNS

Please describe your primary health concern below:

MEDICAL HISTORY

List all names of prescribed medication currently being taken. Include dosage, frequency, how long you have been taking it.

PREVIOUS HEALTH HISTORY/FAMILY HISTORY

LIFESTYLE

ENVIRONMENT

iNFORMED cONSENT

Services

Company

Support

HEALTH INTAKE FORM

health intake form - Intuitive Energy Healing (Video Call)​

Emergency Contact:

How did you hear about Elvira?

Names of other health care practitioners (medical doctor, chiropractor, specialist, physiotherapist, etc.) you are seeing:

CHIEF HEALTH CONCERNS​Please describe your primary health concern below:

MEDICAL HISTORY​​

List all names of prescribed medication currently being taken. Include dosage, frequency, how long you have been taking it.

PREVIOUS HEALTH HISTORY/FAMILY HISTORY

LIFESTYLE

ENVIRONMENT

iNFORMED cONSENT

Services

Company

Support

Subscribe

health intake form - Intuitive Energy Healing (Video Call)

CHIEF HEALTH CONCERNS

Please describe your primary health concern below:

MEDICAL HISTORY