Mantra
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Appointment Procedure
Health Questionnaire
Bios Reiki Master Healer
Mantra
About
Appointments
Appointment Procedure
Health Questionnaire
Menu
Health Questionnaire
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email Address
*
Mailing Address
*
Donation (voluntary)
PayPay
Venmo
US Mail
Occupation
Age, Height, Weight
Have there been any recent weight changes?
Current Health Issues
HEALTH HISTORY
Accidents or Injuries
Serious Illnesses
Chronic Illnesses
Hospitalizations
Operations
Allergies
Current Medications
Nutritional Issues
HABITS
Tobacco
How many packs a day, or if you use chewing tobacco.
Alcohol
Example: I have a glass of wine after dinner.
Street Drugs
Sugar
Example: I drink four cans of soda a day.
Coffee
Please say how many cups of coffee and the approximate size. Example: Four cups a day, size about 16oz(medium/Grande)
Have you ever worked or been exposed to health hazards?
Asbestos, inhalants, chemicals, or radiation? Please explain in detail below.
Have you been in the military?
If Yes, please say how many years.
Typical diet (What foods do you regularly eat?)
Thank you!