NEW CLIENT INTRODUCTION Name * First Name Last Name Date Of Birth (include time and place of birth): * Occupation: * Employer: Primary Care or Alternative Healing Provider(s): * Emergency Contact: * Emergency Contact Relationship: * Emergency Contact Phone * (###) ### #### How did you hear about us? * HEATH INFORMATION What is your height? * What is your weight? How many days per week are you active? * None 1-2 3-4 5-6 Everyday Are you taking any medications or supplements? * Yes No If yes, please list: Are you currently pregnant or nursing? * Yes No If yes, how far along: Do you smoke/vape or drink alcohol? If so, how much? * Do you suffer from chronic pain? * Yes No If yes, please explain: What makes it better (meds, ice, heat, position, etc.)? What makes it worse (movement, weather, stress, position, diet, etc.)? Have you had any orthopedic or traumatic injuries? * Yes No If yes, please list: Please indicate any of the following that apply to you: * Cancer Headaches/Migranes Arthritis Diabetes Joint Replacement High/Low Blood Presssure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains Trauma None of the above Other (Please specify below) Please explain any condition(s) as needed: Other conditions not listed above: Do you have any allergies or sensitivities (including scents and touch)? * Yes No Not Sure Please explain any allergies or sensitivities (including scents and touch): What are your wellness goals? * Do you have any current spiritual practices (yoga, meditation, Tai Chi, journaling, energy healing, prayer, worship, chanting, rituals, breathing exercises, et c.)? If so, what? * What are your spiritual goals? * On a scale from 1-10, how ready are you to make positive changes in your life? * On a scale from 1-10, how confident are you that you can make positive changes in your life? * * What do you hope to receive from your service with Elev8 Soul and Science? * Thank you!
