DR. BETTY'S CONSENT FOR TREATMENT

Therapeutic Touch, Healing Touch, Reiki, Flower Essences, Aromatherapy, Integrated Energy Therapy Therapeutic Touch, Healing Touch, Reiki, Flower Essences, Aromatherapy or Integrated Energy Therapy is not a substitute for regular medical checkups. Detecting infections, tumors, fractures or other hidden conditions is not within the scope of this practice. It remains the patient’s responsibility to seek standard medical treatment if symptoms persist or new symptoms occur. This consent indicates your awareness of the treatment to be administered and the conditions being addressed. The undersigned hereby agrees that no guarantees of result are given or implied. 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:    INTAKE INTERVIEW (Please complete this form in it's entirety.) Date:  Name:  Address:  Date of Birth:  City/State/Zip  Home Phone:  Email:  Work Phone:  Occupation:  Present Ailments:  Are you under a doctor's care?:  Yes No If yes, who?:  of where?:  List any medications/supplements you are taking:  Have you ever experience energy work before?:  Yes No If yes, what type?:  Shiatsu Reiki  Therapeutic Touch Healing Touch  Other: If yes, by whom?:  of where?:  How did you learn about this practice?:   Advertising   Friend   Newsletter Wellness Directory  Website Referred by: LIFESTYLE EVALUATION Marital Status:  Single   Married   Significant Other  Divorced Living Situation:  Alone   Other Adults   Children  Pets  Plants Type of home:  Single Family   Apartment   Quiet Neighborhood  Busy Neighborhood  Energy Level:  Generally Good   Tire Easily   Seasonally Influenced  Stress Influenced Stressors:  Work   Family   Caregiver  Other: Stress Reduction:  Exercise   Meditation   Hobby  Personal Time Spiritual Practice  Other: Exercise Habits:  Regular   Sporadic   Do Not Exercise at this Time  Sleeping Habits:  Sleep Deeply, Rarely Wake Restless, Wake Easily   Remember Dreams  Wake to Use Bathroom, Fall Back Asleep Easily  Other: Eating Habits:  Significant Medical History (surgery, etc):  Physical Exam:  Date of Last Exam: Physician: Significant Scars:  Chronic Problems:  Allergies:    Additional Comments: