Life Spirit Healing- Client Questionnaire-101
Name ______Date______
Address______Email______
City______Zip______Phone______
Occupation______Age ______
In case of emergency please call______Phone #______
Client health history: To provide the most therapeutic service please answer or check what applies to you. Headaches______Allergies ______Back Problems______Injuries______
Photo-Sensitive Medications? Such as Doxycyline, Tetracycline, Retin A, St. Johns Wort?______Other-Medications?______Blood pressure high/low______Cancer______Cysts_____Tumors_____, Stroke______Do you Bruise easily?______HIV______epilepsy____ Diabetes______Heart Disease______Recent surgery______Muscle, bone, joint Problems______Aches and Pains? ______Do you Smoke?______Wear Contacts______Have Hearing aids______Pregnant______How many months______Any other health conditions______Have you used Light Therapy before?_____What kind______
Do you sleep well?______Sensitive to blinking lights?______Massage: Do you like soft touch or deeper touch?______Due to injury or sensitivity, etc., is there any part of your body that you would prefer I not work on?______Sensitive to Essential Oils?_____ Any other health conditions______Doctor,Chiropractor,Acupuncturist you are seeing?______
Ever Hypnotized before? ______What for? ______
How did it go? ______
(There are many different types of hypnotherapists with different styles and what may not work at one time can work at another time. Each person and situation is different.)
CLIENT QUESTIONNAIRE Pg 2
Please check any of the following conditionsthat mightapply to you:
Clinical depression, ___phobias, ___panic attacks, ___psychosis___ schizophrenia,___anorexia, ___bulimia, ___alcoholism, ___drug dependency
Other conditions, please describe: ______
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Family Background______
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Significant Other/Children______
Spiritual Beliefs / Philosophy that can assist you in transforming your issue: ______
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Past: How long has this been happening? When did it start? What was going on when this started? How often has this recurred? Did anyone in your family feel the same way? Did something happen when you were young that felt like what you’re going through now?
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Present: What’s going on in your life today? How is this affecting you now? (work, sleep, health, mood, relationships) Describe how it feels - emotionally and/or in the body.
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CLIENT QUESTIONNAIRE Pg 3
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Future: What would you like to accomplish? What would you like to do instead of this? What would it be like for you to have accomplished this? What are your goals for this session and over the next few weeks, or in general?
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How would you know you were successful? What would be different in your life?_
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Visualization: Beautiful/relaxing/safe place in nature for you: ______
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What relaxes you? ______
______Who can I thank for referring you; or how did you hear about me? ______