New Client Form Let’s get the basics. Name*Sex?*MaleFemaleStarsign?*Age*BirthDate*Email*Telephone*Physical Address*What is the purpose of your visit with me?*Where did you hear about me?*What Treatments are you particularly interested in?*Body Work3 Day Retreat Program7 Day Retreat Program14 Day Retreat ProgramScio BiofeedbackHealth Coach Consultation (NEW!)Mental HealthSupplements Not sureHave you been diagnosed by a doctor? If Yes, please name the diagnosis.Please mark all relevant to your Current Health.1 – Do you have any Allergies?2 – Do you have any Hormone issues?3 – Do you have Lung issues?4 – Do you have any Heart issues?5 – Do you have Spinal issues?6 – Do you have Kidney/Bladder/Urinary Tract issues?7 – Do you have Dietary Issues?8 – Do you have Liver issues?9 – Have you had Surgery?10 – Do you have any Digestive issues?If you ticked in Field 1-10 above, please give more detail here, i.e. (1 – I am allergic to pollen and react annually.)Additional information Relevant to your Health which you have not mentioned in detail above.Are you taking any medicine currently? (Please write the name and purpose of meds and also how long you have been taking it.)*Do you have problems with Sleeping?YesNoDo you drink enough water?YesNoDo you have an active body?Walk Once a weekWalk DailyJog Once a weekJog DailySit most of the timeRarely walk at allAm balanced with my body activityHow would summarize your health challenge in One Single Word?When do you want to book an appointment?Do you want to add anything else?Would you like to receive our NewsletteryesnoSend Please enable JavaScript in your browser to submit the form Well, Naturally mossel bay susan@wellnaturally.co.za (+27) 83- 742-9040 Not sure What Integrative Healing Is? Read more..
