DR. BETTY'S FLOWER ESSENCES INTAKE FORM

ALL INFORMATION IS CONFIDENTIAL When you fill out this form, it will supply the necessary information for a certain flower essence. Flower Essences are natural and will not interfere with any medications you may be taking. However, they are not a substitute for needed medical care. It is important for you to understand that when making personal health decisions that you know our products have not been evaluated or approved by the FDA. I have fully read and understand the foregoing. (By typing your name in the below box it acts as your electronic signature) Electronic Signature:  (type your full name) Date:    FLOWER ESSENCES INTAKE INTERVIEW (Please complete this form in it's entirety that we may be able to process your order properly.) Date:  Name:  Sex:  Male  Female Address:  Date of Birth:  City/State/Zip  Home Phone:  Email:  Work Phone:  Occupation:  Present Ailments:  Are you under a doctor's care?:  Yes No Have you ever used Flower Essences?:  Yes No If yes, please list:  If yes, who is your practitioner?:  What are your main reasons to use the Flower Essences now? (please check all that apply)   To deal with negative or painful emotions   To help in relationships with others   Greater Clarity about my life work and direction   To improve my self-image and feelings about myself   To enhance my creativity and self expressions   To cope with stress and demands of life   For greater spiritual awareness   For physical healing   To bring about a more positive attitude toward life   For help with immediate crisis (describe below)   For long-term inner growth and change   Other Please comment on the three most important areas that you wish to address:  Please give a brief description of your general state of health:    - Physical (Note any significant medical history, diet, exercise, energy lever, etc.)   - Emotional (Feelings about self or others, on-going issues or areas of conflict):    - Mental (Outlook on life, beliefs and attitudes):    - Spiritual (Ultimate sense of purpose, moral or religious values):    How do you feel about your work or other vocational interests?:  How do you feel about your work relationships with others, especially major relationships?:  Briefly discuss your family background:  What are the therapies or significant growth experiences you are now undergoing?:  How did you learn about this practice? (please check all that apply)   Advertising   Friend   Newsletter   Wellness Directory   Website Referred by: