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ELECTRIC HEALING
DEEP SEA DIVE
FAIRY YOGA
Cart
0
Home
About
OFFERINGS
ELECTRIC HEALING
DEEP SEA DIVE
FAIRY YOGA
Blog
PACKAGES & SPECIALS
Events
Schedule a Session
Deep Sea Dive Intake Form
Name
*
Name
First Name
Last Name
Date
*
Date
MM
DD
YYYY
Address
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
*
Date of Birth
*
Date of Birth
MM
DD
YYYY
Emergency Contact
*
Phone
*
Phone
Country
(###)
###
####
Session Information
Referred By
*
Email Address
*
Why do you want this session?
*
What are you passionately excited about in your life right now?
*
What would you like to change about your life right now?
*
Describe your average day:
*
Are you currently under the care of a mental health practitioner?
*
Yes
No
If yes, please specify purpose:
Are you currently under the care of a medical doctor?
*
Yes
No
If yes, please specify purpose:
List current medication and purpose:
*
Previous medical treatment (Include year and treatment)
*
Injuries/Traumas/illnesses still affecting you
*
Surgeries
*
Please mark any of the following that pertains to you
Circulatory
*
Heart Condition
Phlebitis/ Varicose Veins
Blood Clots
High / Low Blood Pressure
Lymphedema
Thrombrosis / Embolism
Other
Skin
*
Allergies
Rashes
Athletes foot
Herpes / Cold Sores
Other
Digestive
*
Irritable bowel syndrome
Ulcers
Other
Other
*
Cancer / tumors
Bladder / Kidney ailment
Diabetes
Drug /Alcohol/Caffeine /tobacco
Chronic fatigue
Chronic pain
Sleep disorders
Migraines /headaches
Anxiety / stress syndrome
Depression
Contact Lenses
Musculoskeletal
*
Bone and joint disease
Tendonitis / Bursitis
Arthritis / Gout
Jaw Pain (TMJ)
Lupus
Spinal Problems
Other
Respiratory
*
Breathing difficulty / Asthma
Emphysema
Allergies
Sinus Problems
Other
Nervous System
*
Shingles
Numbness / tingling
Pinched Nerve
Other
Reproductive
*
Pregnant
Overian / Menstrual problems
Prostate
Other
Additional Client Remarks/Comments:
Thank you!