Patient Forms

Health & Wellness Intake Information

Please take the time to fill this form out completely. All of this information helps me get a better understanding of your body from a energetic prospective. Once I receive this form sessions can be scheduled.

Name

First Name

Last Name

Phone Number

(###)

###

####

How did you learn about Wellness by Shari?

Reasons for seeking energetic sessions:

Experience with other holistic treatments:

Please describe your living situation/social support:

For instance, family, friends, roommates, alone, pets, etc.

Any recent surgeries within the past two years?

If yes, please list.

Is there anyhting in your health history you think I should know?

Do you currently take any supplements or homeopathic remedies? If yes, please list.

Any allergies that I should be aware of? If yes, please list.

Women Only

Are you currently pregnant?

Yes

N/A

Is there any information about your cycle I should know about?

Personal Stress

Rate your personal stress: 1 being the lowest, and 10 being the highest:

Select all the apply:

Where does your stress originate from:

Illness

Work

Relationships

Finances

Other

Patient Forms

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