First appointment? ... A few questions proir to treatment
Hello and thank you for your interest in my Chi Nei Tsang practice. To give me a better understanding of your specific concerns, please provide the following information. I look forward to working with you.
Name: _______________________________________ Date: ____________________
Occupation:
What is the primary reason for seeking this work?
What have you done for relief/healing?
Do you have a specific health concern? (Please describe)
Has there been a medical diagnosis? Y N (If yes, please state diagnosis)
Do you have other areas of pain or concern?
Have you had any abdominal surgeries?
Are you scheduled for a surgical procedure?
Are you taking any medications?
Do you practice meditation, energy work or spiritual healing?
If you are receiving care through other modalities, please list type of care and provider.
Do you have any questions you’d like me to address during the session?
Anything else you’d like me to know?
Name: _______________________________________ Date: ____________________
Occupation:
What is the primary reason for seeking this work?
What have you done for relief/healing?
Do you have a specific health concern? (Please describe)
Has there been a medical diagnosis? Y N (If yes, please state diagnosis)
Do you have other areas of pain or concern?
Have you had any abdominal surgeries?
Are you scheduled for a surgical procedure?
Are you taking any medications?
Do you practice meditation, energy work or spiritual healing?
If you are receiving care through other modalities, please list type of care and provider.
Do you have any questions you’d like me to address during the session?
Anything else you’d like me to know?