Bio-Energy Healing Client Record Form Date MM DD YYYY Name * First Name Last Name Address Email * Phone (###) ### #### Date of Birth Occupation Relationship Status Dependents Past Health History (including major life events) Present Health (including current medication and/or medical or alternative treatments) Reason for having Bio-Energy Healing In order to assess the benefits received from the therapy, please take a few moments to complete this form. Name First Name Last Name Date MM DD YYYY Therapist Treatment No Main Concern Please select the number that best indicates the average level you are experiencing PAIN 0 = painfree, 10 = worst possible 0 1 2 3 4 5 6 7 8 9 10 STRESS/ANXIETY 0 = none , 10 = worst imaginable 0 1 2 3 4 5 6 7 8 9 10 DEPRESSION 0 = none, 10 = extreme hopelessness 0 1 2 3 4 5 6 7 8 9 10 ENERGY LEVEL 0 = very energetic, 10 = very low energy 0 1 2 3 4 5 6 7 8 9 10 SLEEPING 0 = great sleeping, 10 = not sleeping at all 0 1 2 3 4 5 6 7 8 9 10 Thank you!
