A little info about you… Before our first visit, please take 5 minutes to complete the below baseline questionnaire. This helps to give me a little insight into you and what you are seeking from our upcoming sessions. Name First Name Last Name Email Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact First Name Last Name Emergency Contact Phone (###) ### #### Date of Birth MM DD YYYY Reason for visit: Occupation? For how long? Relationships Single Married Separated Divorced Additional relationship background if wanted (option): Do you have children? If so, what are their ages: Do you have siblings? If so, how many: Finances In 3 words (minimum), how do you feel about your finances? Mental / Emotional In 3 words (minimum), how do you feel about your emotional state? In 3 words (minimum), how do you feel about your mental state? Do you feel you can deal with life's ups and downs in a healthy way? Yes No Sometimes :) Physical Do you have any past injuries? If so, please give a brief description? Are you on any medication? Do you suffer from any of the following: (select all that apply) Headaches Dizziness Shortness of breath Cravings Muscle soreness / muscle tightness Joint stiffness Back pain Sore feet High/Low blood pressure Diabetes High/Low blood sugar PMS or other menstrual cycle related issues Any other physical issues or further detail on any of the above? Nutrition On an average day, how much water do you drink? Do you drink coffee or tea? If so, how much per day? Do you drink fruit juices regularly? How would you rate your diet? Very good Moderate Poor Day to day How would you rate your energy level through the day? high moderate low extremely low Do you feel rested when you wake up in the morning? Yes No Somewhat How many hours a night do you sleep, on average? What time do you go to bed? Get up? Do you see health care practitioners? (chiroprator, physiotherapist, naturopath, etc) Do you smoke / vape? If so, how many times a day? For how long (years etc)? Consent to receive treatment I, the undersigned, consent to services received from Sarah Phillips. I understand that these sessions are for stress reduction and relaxation; I may stop the session at any time. I understand the benefits and risks of these services and acknowledge this treatment is not a substitute for medical diagnosis or psychological condition and treatment. I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes. I release Sarah Phillips from any and all legal liability during my participation at the Rekindle Me facility. I assume sole responsibility for my own health and for the results of any consultation, treatment, and coaching provided by Sarah Phillips that may affect my health in any way. Thank you for taking the time to complete this! I look forward to meeting with you soon. Thank you! I look forward to seeing you soon.
