Name
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First Name
Last Name
Email
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Mobile
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Address
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Emergency contact
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(###)
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Occupation
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Do you enjoy your job?
Primary reason for contacting Fieldwork Therapy
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Have others helped you with this problem?
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If yes please list them
What are your expectations for these sessions?
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Please tick any of the following complaints you are dealing with.
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Please elaborate on any of the above issues if needed
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Please mention any other conditions or symptoms not mentioned above.
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Family medical history: Diabetes, Heart problems, High BP, Cancer, Alzheimers, Others.
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Previous surgeries, including dental, with dates.
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Accidents or injuries? If yes, what and where?
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Weight?
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Height?
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How much water do you drink?
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Is you water purified or filtered?
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How much alcohol do you consume each week?
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Do you smoke?
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Caffeine consumption per day? (coffee, tea, matcha, chocolate etc)
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Do you follow a particular diet?
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How much sleep do you get each night?
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Do you exercise?
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If yes which type?
Do you take recreational drugs or plant medicine? If yes please elaborate.
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Do you take any medication?
Do you take supplements?
Have you had any toxic exposure?
Describe any traumatic life events, physical or emotional.
List areas in the body of complaint or tension, describe.
Which word best describes your current state of health?
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Is your home environment peaceful or stressful most of the time?
Current pain level (1= very low, 5= very high)
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Current stress level (1= very low, 5= very high)
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Current energy level (1= very low, 5= very high)
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Please select the most emotionally draining relationships in your life.
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I do you feel supported?
Please select the emotions that best reflect how you feel most of the time.
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Select as many as you like.
Regaining well-being can require a strong personal commitment. How ready are you to make the lifestyle changes, the diet changes and attitude changes that may be needed to gain good health?
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I have read the above information and have filled out the form to the best of my knowledge. I understand the questions on this form are being asked in order to better access my current circumstances and their relationship to my well-being and that all information will be kept confidential. I further understand I am voluntarily agreeing to have a relaxation therapy session that no medical claims or promises of healing have been given.
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Concession code
Date
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