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Amanda Weller your wellbeing - naturally Energy Medicine, Distance Healing, BodyTalk

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Health & Wellbeing Form

I am delighted you have booked a session with me.

Please now complete this online form. Part A covers consent and Part B concerns your health and wellbeing. Once you have submitted this form, I will then be able to start working with you.

I look forward to receiving it.

Many thanks,

Amanda




Part A: Consent

Before continuing to the health questionnaire please enter your personal details and read carefully through the notes below. At the end of the questionnaire you will be asked to confirm that you agree to the terms detailed.
Fields marked * are mandatory.


*First Name:


*Last Name:


*Date of Birth:


*Address:


*Home Telephone:


*Mobile Telephone:


*Email Address:


Skype ID:


Occupation:


*Referred by:


*I understand that the information on this form and any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. The information excluding my name may be used to help others further understand the efficacy and use of this healing system:
Yes  No


Part B: Health and Wellbeing
Please answer the following questions honestly and to the best of your ability.

Describe the problem(s) for which you seek help. Please include dates when each problem occurred:


Past medical history (previous injuries, accidents, surgeries, etc.). Please describe and include approximate dates:


List the medications (including over the counter) you are presently taking:


What daily activities are you finding difficult or are limited because of your above complaints:


Have you ever had this(these) problem(s) before?


What are your goals from working with Amanda?


Please list any other kind of healthcare professional you are seeing for this(these) problem(s):


Please list any medical tests you have had within the past year:



Please check any of the following feelings you have experienced in the last few months:

  Abused
  Criticised
  Overworked
  Paralysed
  Depressed
  Rejected
  Despair
  Helpless
  Hopeless
  Paranoid
  Overwhelmed
  Muddled
  Persecuted
  Guilty
  Easily irritated
  Anxious
  Sad
  Grieving
  Unable to grieve
  Apprehensive
  Agitated
  Uneasy
  Distress
  Fearful
  Impatient
  Intimidated
  Restless
  Panic
  Intolerant
  Uncertainty
  Aggravated
  Annoyed
  Angry
  Outraged
  Nervous
  Worried


Please select the word that best describes the level of stress for the below listings:

My family stress is:  None   Minimal   Moderate   Severe
My relationship stress is:  None   Minimal   Moderate   Severe
My work stress is:  None   Minimal   Moderate   Severe
My financial stress is:  None   Minimal   Moderate   Severe
My health stress is:  None   Minimal   Moderate   Severe
Other stress is:  None   Minimal   Moderate   Severe
Please list any other causes of stress:



How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc.?


Do you exercise? And if so, what kind and how often?


How many hours a night do you sleep?


Is your sleep restful?  Yes    No

If not, please explain:



Please list any specific areas of pain (ie. "Neck") and mark the circle that best describes the level of discomfort on a scale of 1 to 10, using the guide below.

1: Slight awareness of discomfort.
2-3: Awareness of discomfort as an aggravation.
4-6: Pain is strong but you are still functional.
7-9: Pain is so strong you are unable to function normally.
10: You feel like you need to go to hospital.

Area of pain

Level of discomfort:  1   2   3   4   5   6   7   8   9   10 

Area of pain

Level of discomfort:  1   2   3   4   5   6   7   8   9   10 

Area of pain

Level of discomfort:  1   2   3   4   5   6   7   8   9   10 

Area of pain

Level of discomfort:  1   2   3   4   5   6   7   8   9   10 

Area of pain

Level of discomfort:  1   2   3   4   5   6   7   8   9   10 

Area of pain

Level of discomfort:  1   2   3   4   5   6   7   8   9   10 


Comments
Please make any additional comments that will help clarify the exact location and nature of discomfort/pain (eg: "pain in the back of my right hip when I get up out of a chair").


And Finally ...
Please use this box if there is anything else you would like to mention before your session



Once you have completed the form please read through the Disclaimer information below, tick the box at the bottom of the page to confirm that you agree to the terms detailed and click "Send" to submit.

Disclaimer:
  • I understand that the session provided by Amanda Weller is intended to enhance relaxation, increase communication within areas of the body and to educate me to possible energetic or emotional blocks that may create pain and disease.
  • I acknowledge that this session is non-invasive, safe and objective and that it utilises the body's own innate intelligence to re-establish communication within itself.
  • I understand that participation in a session is voluntary and that at all times I may choose to end my participation.
  • I understand that so called 'detoxification' symptoms or release during the 24-48 hours following the session may be experienced, particularly if I have been experiencing chronic or heightened levels of stress.
  • I understand that the session is not a substitute for medical treatment or medications.
  • I am aware that Amanda Weller does not diagnose and nor does she prescribe medication.
  • I am aware that any medical issues or concerns should be addressed with a qualified physician.
  • I understand that information exchanged during any session is educational in nature and is intended to help me become more familiar and conscious of my own health status and is to be used at my own discretion.
  • I agree to pay GBP80.00 per BodyTalk session for anything up to 1 hour in duration (sessions can last 20 mins) or GBP50.00 per Reflexology treatment / Quantum-Touch session.
  • I understand payment is required in full before the appointment. Payment may be made by cash, cheque, bank transfer, PayM or PayPal - there is a surcharge on all payments by PayPal to cover the charges.

Cancellation Policy:
  • I understand that to avoid a cancellation fee, at least 48 hours notice must be given.
  • Cancellation without the required notice will be charged the full fee.

Confidentiality Policy:
  • I understand that the information on this form and any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. The information excluding my name may be used to help others further understand the efficacy and use of this healing system.

Please select one of the following:
Yes   No    I am happy to be contacted every now and again by Amanda Weller with information concerning health and wellbeing. I understand that my details will never be passed to any third parties.


Your Agreement
 I have read, understood and agree with the above Disclaimer, Cancellation and Confidentiality policies. All of the information I have provided is accurate to the best of my knowledge.


     

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