CLIENT INTAKE FORM – energy balance @ bondi

Date *

Day/Month/Year

Name *

First

Last

Email *

Address *

Address

Date of Birth

Day/Month/Year

Occupation

Referred By

Home Phone Number

Work Phone

Mobile *

Emergency contact name *

Relationship with Emergency contact *

Emergency contact Number/s *

Are confidential messages OK? *

Health care professionals you are currently seeing *

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, Insert name / date *

I understand that the Eden 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 EEM 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.

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 diagnosis for them, treatments you have tried, and their effectiveness: *

Please tick if appropriate

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 tick if appropriate

Other Significant Illnesses

Surgeries / Dates – Please list below.

Describe any major accidents or traumatic events and approx. dates *

Allergies (drugs, chemicals, foods, airborne allergies, etc.)

Current Medications: *

Name/Purpose/Dosage /Frequency/Taken for how long?/Any adverse reactions?

Current Nutritional and Herbal Supplements *

Name/Purpose/Dosage /Frequency/Taken for how long?/Any adverse reactions?

Alcohol *