Medical Questionnaire

GENERAL INFORMATION


Name (required)

Referred By (required)

Contact (work)

Contact (direct)

Email

Date of Birth:

Height:

Weight:

Address

PERSONAL INFORMATION


Relationship Status

Number of Children

Spouse / Partner Name

Your Occupation

Do you enjoy your occupation

Yes No 

EMERGENCY CONTACT


Emergency Contact

Relationship

Phone Number

MEDICAL INFORMATION


Water Consumption

Optimal Life Vessel results require drinking one gallon (16 cups / 128 oz.) of water daily starting the day before your first Life Vessel session and for the subsequent 14 days.


Do you anticipate any difficulty with this?

Yes No 

If 'yes', please explain:

Health Questions

Describe your current state of health:

What is your primary reason for visiting us?

Other health concerns?

Describe how stress currently affects your life?

What are your health goals?

Allergies and Sensitivities:

Describe any special medical attention or assistance you'll need while visiting the center?

FAMILY MEDICAL HISTORY

Fathers Age



Fathers Deceased Age



Fathers Health Issues

Mothers Age



Mothers Deceased Age



Mothers Health Issues

(1)Siblings Age



(1)Siblings Deceased Age



(1)Siblings Health Issues

(2)Siblings Age



(2)Siblings Deceased Age



(2)Siblings Health Issues

GENERAL QUESTIONS


Do you generally feel supported in your relationships?

Yes No 



Is your home environment stressful?

Yes No 



Are you in fear regarding your health?

Yes No 



Do you practice meditation or relaxation techniques?

Yes No 



Do you adhere to a particular diet?

Yes No 

Are there any pins or wires in your body?

Yes No 



Do you wear contact lenses?

Yes No 



Do you drink more than one alcoholic beverage a day?

Yes No 



Do you smoke?

Yes No 



Do you use recreational drugs?

Yes No 


What drives you, inspires you and gives you a sense of purpose?

Can you describe your exercise and/or daily activity routine?

Regaining well-being usually requires a strong personal commitment. How ready do you feel you are to make some lifestyle changes, diet changes and possibly attitude changes in your pursuit of better health?

Life Vessel Disclaimer

I have read the above information and have completed this form to the best of my knowledge. I understand that the questions on this form are being asked in order to better assess my current condition and their relationship to my well-being. I further understand that I am voluntarily agreeing to have a relaxation therapy session in the Life Vessel and that no medical claims or promises of healing have been given. Lastly, I acknowledge that the Life Vessel treatments do not supersede the recommendation of my personal physician nor are intended to replace the conventional standard of medical care.

Payment Policy

Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. Although some of our services may be covered through your insurance plan, we do not bill your insurance and reimbursement is the responsibility of the patient. We are pleased to provide billing codes and any other documentation that will assist you through this process. We accept payment in the form of cash, check or credit card. If you must cancel or reschedule an appointment, please do so at least 24 hours before the scheduled appointment time. Your signature below signifies your understanding and willingness to comply with these policies.