RUTH MUELLER ENERGETICS

141 East Highway 66, Albuquerque, NM 87123 (505) 980-7952

Name ______Date ______

Address ______Marital Status ______

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Email Address ______Phone ______

Would you like to receive Energetics e-mail notices? ______Alternate Phone ______

Please list your reasons for seeking treatment at this time ______

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Please list any current signs and symptoms you are experiencing ______

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Have you sought out other treatment for these conditions?_____ Was it helpful?______Please describe______

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On a scale of 1 to 10 (1 being little, 10 being excessive) where would you rate your life stress? ______

Is your stress physical, emotional, interpersonal, mental, and/or spiritual?______

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Do you have set times in your days or weeks to nurture yourself? ______Please describe ______

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Do you feel supported and understood by those closest to you?______

Do you have a spiritual or religious practice?______

When out of balance do you feel agitated, depressed, suicidal, lethargic, etc. Please describe ______

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Do you often feel out of balance?______

What helps you find your balance again?______

The following questions are being asked to assist in making recommendations for assisting the body to enter into a greater state of balance. Please provide more detail on the back of this sheet if more space is needed.

Please describe your typical daily diet ______

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How much water do you drink? ______What is your water source? ______

Do you experience and cravings?______What do you crave? ______

Have you dieted in the past or made any big changes in your diet?______Please describe. ______

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Do you have an exercise routine?_____ Please describe. ______

Do you feel you should be more active? _____ Please describe. ______

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Please list any current health problems ______

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Please give a brief medical history ______

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Please list and past and current health problems found in your immediate family ______

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Are you currently taking any vitamin, herbal, homeopathic, or vibrational supplements? ______Please list the supplement and what you are taking it for ______

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Are you currently taking any prescription or over the counter medications? ______Please list the medication and what you are taking it for ______

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Do you have any known allergies? ____ Please list ______

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