BodyTalk System: Effective Convenient Distance Healing Therapy

New Client Intake Form
If booking an appointment for someone else, please provide the following information about yourself:
First name:	* required
Last name:	* required
Relationship to person receiving treatment:	* required
Email address:	* required
Telephone Country Code (outside US/Canada):	* required
Area code + Telephone Number:	* required
Mailing address:
Please Enter Client's Information Below:
First name:	* required
Last name:	* required
Gender:	Male Female
Email address:	* required
Telephone Country Code (outside US/Canada):	* required
Area Code + Telephone Number:	* required
Mailing address:
Best way to contact you to confirm appointment:	Email. Telephone.
Would you like to be on the telephone with me during your session?	Yes No
Health & Well Being History Form
Please check off applicable areas of concern:
	Physical Well-Being: CardioVascular Respiratory Digestion Urinary Reproductive Sexual Dysfunction Nervous System Sleep Muscles / Joints Circulatory Skeletal / Bones Brain / Spinal Immune System Lymphatic Skin Dental Vision Hearing Weight Condition Recent Injury Surgery Allergies / Intolerances Addictions Exposure to Toxins (eg., heavy metals) Rehabilitation Pregnancy Vaccinations Bacterial / Viral Infection Parasites Chronic Pain Other Symptom or Condition Not Mentioned Mental / Emotional Well-Being: Depression Mood Swings Anxiety Panic Concentration Anti-Social Behaviour Relationship Issues Self-Esteem Phobias Nightmares Limiting Beliefs Other Symptom or Condition Not Mentioned
Of the above areas of concern, please indicate below which area(s) you would like addressed. Please list your symptoms, any medications you are taking, any conditions diagnosed and any other information regarding this condition I should be aware of. In brackets please rate the severity of each symptom / condition you discuss on a scale from 0 to 10 (10 being most severe).
THANK YOU!