Confidential Client Questionnaire

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Thank you for taking the time to complete this questionnaire - I know some of the questions are challenging. Email me if you need to ask anything. Love Tracey

tracey@ultimatehealing.au

Email*

example@example.com

Mobile*

Country CodeMobile Number

How did you hear about me?

Your Date of Birth

Date of Birth and Current Age in Years

Occupation/Physical Duties

Married, single, divorced?

Children and if so ages?

General Health? 1 Poor 5 Excellent*

	1	2	3	4	5

1 is Poor, 5 is Excellent

Pain or discomfort Level? 1 Extreme Pain 5 No Pain*

	1	2	3	4	5

1 is Extreme Pain, 5 is No Pain

Stress Level? 1 Stressed 5 No Stress*

	1	2	3	4	5

1 is Stressed, 5 is No Stress

Energy Level? 1 Low 5 High*

	1	2	3	4	5

1 is Low, 5 is High

How do you feel in yourself - happiness levels? 1 Sad 5 Happy*

	1	2	3	4	5

1 is Sad, 5 is Happy

Do any of the following conditions or symptoms currently apply to you? Please select.

When did any symptoms start, how long have they been going on for and does anything make them better or worse?

How do your current symptoms and feelings affect your health, behaviour and emotional state?

Any major surgery, accidents, serious illnesses, lifestyle changes, deaths, divorce, moving, traumas in the last 3 years or if relevant?

Current medication or nutritionals and how long have you been taking them?

General description of normal diet and water intake? Any allergies?

Please describe your sleeping and exercise patterns? Do you sleep well and wake feeling refreshed?

Please describe your hobbies and interests? Do you do these regularly?

Are you currently under the care of any other health care professionals? Please supply their name and contact details

What are your biggest fears or phobias? Please describe

Who have been the most negative and positive influences in your life? Please describe

What are your dreams? What do you want to achieve in your life?

Please describe in detail how you want to feel.

What does your body need to heal? If you knew what would you say?

What is your reason for requesting the healing today? Please describe the priority issues you would like addressed. What are your expectations and what do you wish to achieve from your healing? Your intention for the healing is very important.

Is there anything that you think I should be informed of that was not included in this questionnaire or something that you don't want to share or tell me?

This is not compulsory - Sometimes in life we are given a chance to take a long, hard look at our life... and actually do something about it. Now is one of those chances to change your life and your health. Take advantage of it, and this time... really do something!

What are the things in your life you will change when you reach your perfect state of mind and health?

What is really important to you in the long term? What would you like to achieve within the next year, 5 years, 10 years? How do you want to be remembered?

If money wasn't an issue, how would you spend your time?

What will you be doing when you feel your life is perfect?

What would you be doing if you were told you had 6 weeks to live?

Disclaimer and Authority:

Please understand that my services balance energy and that I do not prescribe medications, diagnose diseases or take the place of conventional medicine. It is your own personal responsibility to accommodate whatever your body presents with and consult your health care provider if symptoms persist. I ask you to accept and understand, by signing this form, that I cannot give you any guarantees of success or accept any liabilty in my sincere effort to alleviate your pain and secure a better way of life for you.

My form of therapy advocates a self-responsibility model of healing which requires your participation and involvement. You are the healer of yourself, guided and supported by me as the practitioner and coach.

By signing this form you are also stating that the information given is correct. All information is strictly confidential unless you consent to me discussing it with another professional. Please only sign this form if you completely understand its contents and are totally happy to receive treatment.

By signing below you also give permission for future contact regarding related information via mail, email, facebook or phone.

With informed consent.

Signature and Date*

Signature and Date

Confidential Client Questionnaire for Ultimate Healing