_Heaven On Earth Healing
A resource for healing, inspiration and wisdom that
honors and facilitates body- mind- spirit
“Supporting the evolution of Life through personal transformation”
_
Name:
______________________________________________________________________________________
Address:
______________________________________________________________________________________
City: ________________________ State: ______________ Zip:___________________
Phone:(day) ______________________________
(evening) ______________________________
(cell) ______________________________
Email Address: ________________________________________________________________________
Date of Birth: ____________
(mm/dd/yyyy)
Emergency Contact:
________________________________________________________
Relationship: ____________________________________________
Emergency Contact Phone: ________________________________
How did you hear about us? (phone book, community board, news print, health & wellness expo/fair, class/workshop, web site, personal recommendation )
If you were personally referred who can we thank?
Please describe your reason for seeking services at this time?
And/or what services do you feel you need at this time? Please refer to the Client bill of rights form for a complete description of services. ( ie. Life Wellness Coaching, Qigong or Reiki energy medicine, or Shiatsu Asian Bodywork therapy or other services )
MEDICAL HISTORY
Services provided from Heaven on Earth Healing Arts are considered Complementary and Alternative Health Care. Do not discontinue or alter medical treatment without first obtaining appropriate medical advice.
Do you have any medical conditions? If so please list what they are and when the condition first occurred
Have you ever had surgery? When? Where anatomically?
Are you presently taking medications? What condition is this prescribed for? How long have you been taking them?
Please list below
Medications & Reasons for taking
SUBSTANCE USE
Do you drink alcohol? Smoke cigarettes or tabacco? caffeine? Sugar (addiction)? How often?
Any other mood altering drugs other than prescribed by a doctor?
PHYSICAL EXERCISE OR MEDITATION
Do you have a healthy regimen? How often do you do this activity?
TRAUMA ~ ABUSE ~ EXTREME STRESS
All information will be kept confidential under the state of Minnesota.
Have you ever experienced: trauma, abuse or extreme stress for any length of time?
Briefly what happened? When and for how long?
Are you under the care of other health care professionals? Both allopathic or complementary & alternative health care practitioners?
What if any are you currently taking: over the counter drugs, vitamins, herbal or homeopathic remedies?
TRADTIONAL CHINESE MEDICINE (TCM) ASSESSMENT
SEASONS circle all that apply
Least favorite season(s) ( winter , spring, summer, late summer, fall )
Least favorite climate(s) ( cold, hot, dry, humid, wind)
What do you experience during these least favorite seasons and climates?
QUALITY OF SLEEP
What is your amount or quality of sleep?
Trouble falling or staying asleep?
Do you dream? Do you remember them, if so are they meaningful or very abstract?
ENERGY LEVEL
Do you notice any change in your energy level before or after certain foods, or at certain times of the day or certain activities or encounters? When are you most / least energized?
DIGESTION AND ELIMINATION
How’s your appetite?
Foods and Fluids you consume most often ( daily / weekly / monthly ) Cravings? What & when?
Any fullness or discomfort before or following a meal?
Any unusual tastes or lack of?
Circle all that apply
Heart burn, acid reflux, nausea, belching, flatulence, intestinal rumbling, hot or cold sensations on the surface of the skin, aversion to warm or hot things, aversion to cool or cold things?
Urinary: frequent, difficulties, painful, clear or concentrated in color, incontinence
Bowel movements: loose, dry, mucusy, frequent, not frequently enough, any discoloration that is regular, normal is one bowel movement for each main meal you have. Example: A normal bowel function would be 3 for 3 main meals per day.
ACHES & PAINS OR OTHER SENSATIONS
ACHES: Where?
______________________________________________________________________________________
PAIN: Where? ______________________________________________________________________________________
OTHER SENSATIONS: What & where? ______________________________________________________________________________________
Do they seem to be fixed in one or more locations or do they seem to migrate, appear disappear?
What brings you relief? Cold or hot packs, light or deep pressure?
TRADITIONAL CHINESE MEDICINE continued.
REPRODUCTIVE CONCERNS
Prolapsed organ, infertility, low libido, Impotence?
FOR WOMEN:
Are your periods on a normal 28 day cycle? At the time of your appointment I may be asking you where you are at in your cycle? What’s the flow like? The color? The quality? Do you have pms, pain, cramping? Number of pregnancies? Miscarriages/ abortions?
MENTAL & EMOTIONAL HEALTH ~ Mind Body Medicine Assessment & TCM Assessment
Do you currently experience unhealthy patterns of thoughts, emotions or behaviors that you would like to be without? If so what are they?
MENTAL ALERTNESS: Overactive / under active foggy headed?
Mental restlessness, difficulty staying focused, confusion, loss of long or short-term memory?
What emotions do you feel most often on a D =Daily, W= Weekly, M= Monthly basis?
Which emotions have become a problem for you?
Love
Peace / calm
Excitement in excess
Anxiety of known or unknown origin
Frustration
Agitation
Irritability
Worry Grief Sadness
Sorrow
Guilt
melancholy
Depression
Apathy /lack of feeling
Fear
Terror
Shock
Fright
Pensiveness / over-thinking
Long term studying
Excessive mental thinking or concentration
For questions contact Theresa May
Heaven on Earth Healing
612-345-1537
Return this “client history form” and a signed “client bill of rights form” (signature page only) via email, postal service mail, or bring this form with you to your appointment.
Send to:
T.May64@gmail.com or Theresa@HeavenonEarthHealing.com
Theresa May
1597 Arundel Street
St. Paul, MN 55117
۞ 7th revision 11/14/11 (2011 CLIENT HISTORY FORM.doc)
A resource for healing, inspiration and wisdom that
honors and facilitates body- mind- spirit
“Supporting the evolution of Life through personal transformation”
_
Name:
______________________________________________________________________________________
Address:
______________________________________________________________________________________
City: ________________________ State: ______________ Zip:___________________
Phone:(day) ______________________________
(evening) ______________________________
(cell) ______________________________
Email Address: ________________________________________________________________________
Date of Birth: ____________
(mm/dd/yyyy)
Emergency Contact:
________________________________________________________
Relationship: ____________________________________________
Emergency Contact Phone: ________________________________
How did you hear about us? (phone book, community board, news print, health & wellness expo/fair, class/workshop, web site, personal recommendation )
If you were personally referred who can we thank?
Please describe your reason for seeking services at this time?
And/or what services do you feel you need at this time? Please refer to the Client bill of rights form for a complete description of services. ( ie. Life Wellness Coaching, Qigong or Reiki energy medicine, or Shiatsu Asian Bodywork therapy or other services )
MEDICAL HISTORY
Services provided from Heaven on Earth Healing Arts are considered Complementary and Alternative Health Care. Do not discontinue or alter medical treatment without first obtaining appropriate medical advice.
Do you have any medical conditions? If so please list what they are and when the condition first occurred
Have you ever had surgery? When? Where anatomically?
Are you presently taking medications? What condition is this prescribed for? How long have you been taking them?
Please list below
Medications & Reasons for taking
SUBSTANCE USE
Do you drink alcohol? Smoke cigarettes or tabacco? caffeine? Sugar (addiction)? How often?
Any other mood altering drugs other than prescribed by a doctor?
PHYSICAL EXERCISE OR MEDITATION
Do you have a healthy regimen? How often do you do this activity?
TRAUMA ~ ABUSE ~ EXTREME STRESS
All information will be kept confidential under the state of Minnesota.
Have you ever experienced: trauma, abuse or extreme stress for any length of time?
Briefly what happened? When and for how long?
Are you under the care of other health care professionals? Both allopathic or complementary & alternative health care practitioners?
What if any are you currently taking: over the counter drugs, vitamins, herbal or homeopathic remedies?
TRADTIONAL CHINESE MEDICINE (TCM) ASSESSMENT
SEASONS circle all that apply
Least favorite season(s) ( winter , spring, summer, late summer, fall )
Least favorite climate(s) ( cold, hot, dry, humid, wind)
What do you experience during these least favorite seasons and climates?
QUALITY OF SLEEP
What is your amount or quality of sleep?
Trouble falling or staying asleep?
Do you dream? Do you remember them, if so are they meaningful or very abstract?
ENERGY LEVEL
Do you notice any change in your energy level before or after certain foods, or at certain times of the day or certain activities or encounters? When are you most / least energized?
DIGESTION AND ELIMINATION
How’s your appetite?
Foods and Fluids you consume most often ( daily / weekly / monthly ) Cravings? What & when?
Any fullness or discomfort before or following a meal?
Any unusual tastes or lack of?
Circle all that apply
Heart burn, acid reflux, nausea, belching, flatulence, intestinal rumbling, hot or cold sensations on the surface of the skin, aversion to warm or hot things, aversion to cool or cold things?
Urinary: frequent, difficulties, painful, clear or concentrated in color, incontinence
Bowel movements: loose, dry, mucusy, frequent, not frequently enough, any discoloration that is regular, normal is one bowel movement for each main meal you have. Example: A normal bowel function would be 3 for 3 main meals per day.
ACHES & PAINS OR OTHER SENSATIONS
ACHES: Where?
______________________________________________________________________________________
PAIN: Where? ______________________________________________________________________________________
OTHER SENSATIONS: What & where? ______________________________________________________________________________________
Do they seem to be fixed in one or more locations or do they seem to migrate, appear disappear?
What brings you relief? Cold or hot packs, light or deep pressure?
TRADITIONAL CHINESE MEDICINE continued.
REPRODUCTIVE CONCERNS
Prolapsed organ, infertility, low libido, Impotence?
FOR WOMEN:
Are your periods on a normal 28 day cycle? At the time of your appointment I may be asking you where you are at in your cycle? What’s the flow like? The color? The quality? Do you have pms, pain, cramping? Number of pregnancies? Miscarriages/ abortions?
MENTAL & EMOTIONAL HEALTH ~ Mind Body Medicine Assessment & TCM Assessment
Do you currently experience unhealthy patterns of thoughts, emotions or behaviors that you would like to be without? If so what are they?
MENTAL ALERTNESS: Overactive / under active foggy headed?
Mental restlessness, difficulty staying focused, confusion, loss of long or short-term memory?
What emotions do you feel most often on a D =Daily, W= Weekly, M= Monthly basis?
Which emotions have become a problem for you?
Love
Peace / calm
Excitement in excess
Anxiety of known or unknown origin
Frustration
Agitation
Irritability
Worry Grief Sadness
Sorrow
Guilt
melancholy
Depression
Apathy /lack of feeling
Fear
Terror
Shock
Fright
Pensiveness / over-thinking
Long term studying
Excessive mental thinking or concentration
For questions contact Theresa May
Heaven on Earth Healing
612-345-1537
Return this “client history form” and a signed “client bill of rights form” (signature page only) via email, postal service mail, or bring this form with you to your appointment.
Send to:
T.May64@gmail.com or Theresa@HeavenonEarthHealing.com
Theresa May
1597 Arundel Street
St. Paul, MN 55117
۞ 7th revision 11/14/11 (2011 CLIENT HISTORY FORM.doc)
