Date:              

Your Name:
Age:
Address:
City:
State/Province
Zip/Postal code:
Phone:
Cell Phone:
Email:
Referred by:
Chief Complaints
General:
Physical:
Mental:
Emotional:
Spiritual:	If your life could change from this moment forward and be anything you desire it to be, what would be different from now?
	What do you want to gain from this session?

Are you  wearing any magnets on your body or in your clothing? If so, we advise that you remove them to avoid subtle energies being misrouted.

** Please turn off your cell phone, PDA, or other devices until the end of the session. Thank you!

Do you have any implanted medical devices such as a pacemaker, pain pump or any other such item that is electronic in nature? If so please advise your practitioner!

Yes    No