CLARE PATRICIA - PRE CLIENT SESSION FORM

This form is to help give a better understanding of your PHYSICAL & EMOTIONAL body. I'm so excited to journey the 5 Elements with you during our HEALING HAIR session.

Please take the time to feel into your intention for our session & what you would like to receive working together.

Name

please take a moment to feel into and write down your INTENTION for our time in your Healing Hair session together

1.Below are some things you may experience when it comes to your Emotional health , please tix the boxes that are relevant to you

2. Below are some questions regarding your sleep quality .

3. when it come to your energy levels ,how would you describe your energy ? Do you get sleepy after eating? How is your overall energy?

4. How is your appetite? and do you experience any of the following?

5a. How is your stool ? please select what category your bowel movements would fit into

5b. How often do you use your BOWELS per day ?

6. when you are needing to go to the bathroom to urinate Do you have urgency?or Do you often forget to go to the bathroom?

7. Do you have a regular menstruation cycle ? How many days is your cycle? Do you experience pain before or during your cycle?

8. Have you experienced Menopause , or do you have any symptoms of ?

9. Do you experience HEADACHES frequently? If so What is your area of pain?

10. Do you experience any of the following dizziness types

11. How is your eye sight , do you experience any of the following ?

12. How is your Hearing , Do you experience Tinnitus "ringing in your ears" ?

13.Do you ever experience any type of Numbness in your body ?

14.If you had to put your body temperature into a category what category below would you fit into?

Are you taking any prescription and/or over-the-counter medication? (Including medical & non-medical cannabis) If so, please list all medication, dosages, length of use, and reason/diagnosis for taking medication.

Do you have any medical history we should know about?

All information is kept confidential.

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