Healthworks Application

Download Applicationpdf.png

Application Form

Your Name* (required)

Your Email* (required)

Address* (required)

Date of Birth* (required)

Today's Date* (required)

Home Phone* (required)

Work Phone* (required)

Occupation* (required)

Who Referred You

Relationships

Partner (Name & Birth Date)

Children

Relationship Status

How Long

Previous Marriage/Relationships

Height* (required)

Weight* (required)

What Life/Health Challenge Brings You For Healing* (required)

List Current Medications, Include Vitamins, Herbs, Natural Remedies* (required)

Surgeries-Accidents-Fractures-Injuries-Emotional Traumas* (required)
Please Include Date and a Brief Description

General Medical Information

Place an appropriate letter beside any of the following that you have experienced C for current, R for recent (last 6 months), P for past (longer than 6 months)

Anxiety* (required)

Arthritis* (required)

Asthma* (required)

AutoImmune Disease* (required)

Back Pain* (required)

Bronchitis* (required)

Cancer* (required)

Carpal Tunnel* (required)

Constipation* (required)

Depression* (required)

Diabetes* (required)

Diarrhea* (required)

Eating Disorder* (required)

Emotional Changes* (required)

Epilepsy* (required)

Eye Problems* (required)

Fatigue* (required)

Gas/Bloating* (required)

Glasses/Contacts* (required)

Hair Piece* (required)

Headaches* (required)

Hearing Problems* (required)

Heart Disease* (required)

High Blood Pressure* (required)

Indigestion* (required)

Insomnia* (required)

Leg Pain* (required)

Muscle Cramps* (required)

P.M.S.* (required)

Pneumonia* (required)

Pregnancy* (required)

Skin Problems* (required)

Stress* (required)

Swallowing Difficulty* (required)

T.M.J* (required)

Taste/Smell Problem* (required)

Other* (required)

Briefly Explain Areas Checked

Please List The Practices, Treatments, And Therapies In Your Current Wellness Program* (required)

Describe A Typical:

Breakfast* (required)

Lunch* (required)

Dinner* (required)

Snacks* (required)

Beverages* (required)

Cancellation Policy: If you are unable to keep your appointment, please call the day before. Late cancellations and missed visits are billed as a session.

I REALIZE THAT A HEALER IS NOT A DOCTOR AND CANNOT PRESCRIBE, DIAGNOSE, OR TREAT SPECIFIC CONDITIONS. ENERGY HEALING, INCLUDING, BUT NOT LIMITED TO HEALING TOUCH, FOCUSING, SHAMANIC JOURNEYS, PROMOTES BALANCE IN THE HUMAN ENERGY FIELD WHICH MAY OR MAY NOT RESULT IN HEALING OF THE PHYSICAL BODY. I, BEING OF SOUND MIND AND EXCERCISING MY FREEDOM OF CHOICE, DO WILLINGLY DESIRE ENERGY HEALING THERAPY.