Reiki Client Intake Form

First Name*

Last Name*

Email Address*

Date of Birth*

Are you currently under the care of a physician?* Are you currently under the care of a physician?* yes no

If yes, physician's name & contact number*

How would you describe your current health?*

Do you have any concerns? (Please give details of any major illnesses or operations in the past 5 years)

How would you describe your energy levels?

Do you find it easy to relax?

Do you drink alcohol? Do you drink alcohol? yes no

If yes, how much alcohol do you consume? please give details

Do you smoke? Do you smoke? yes no

If yes, how many per week on averge?

Do you take drugs? Do you take drugs? yes no

If yes, Please give details of any recreational drugs consumed and how often - is it purely recreational or habitual?

Do you have any allergies? Do you have any allergies? yes no

If yes, Please give details?

Do you exercise? Do you exercise? yes no

If yes, please give details of your weekly exercise output?

Do you find it easy to sleep? How many hours per night?

Do you have cancer?* Do you have cancer?* yes no

Do you have cancer?* Do you have cancer?* yes no

Do you have Appendicitus?* Do you have Appendicitus?* yes no

Do you have any broken bones* Do you have any broken bones* yes no

Are you fitted with a pacemaker?* Are you fitted with a pacemaker?* yes no

Do you have diabetes?* Do you have diabetes?* yes no