Polarity Health Education Client Information Form by nym11541


									                       Polarity Health Education Client Information Form

Name ________________________________________________ Date __________________

Address ______________________________________________ City___________________

State ________________________________________________ Zip ___________________

Telephone (home) _____________________________________ Work___________________

Cell Phone ___________________________ Email __________________________________

Emergency Contact Name __________________________ Phone ______________________

Age ________________ Date of Birth ____________________ Occupation _______________

Referred By _______________________________
Primary Reason for Appointment _________________________________________________

Areas of Complaint, Pain or Tension ______________________________________________

Health Goals _________________________________________________________________

Are you presently under the care of a physician? _________For What ____________________

List any Medications You are Using _______________________________________________

List Supplements of Herbs You are Using __________________________________________

Have You Ever Has any Serious disease conditions __________________________________

Are you Pregnant ________Have you Ever Had Polio__________Are you HIV Positive______

Are you Contagious___________

Circle All That Apply Now or in the Past

Skin Problems                    Digestive Problems           PMS
Allergies                        Constipation                 Painful Menstruation
Blood Pressure Problems          Diarrhea                     Lack of Menstruation
Varicose Veins                   IBS                          Headaches
Spinal Problems                  Chronic Fatigue              Migraines
Arthritis                        Anemia                       Chronic Muscle Tension
Osteoporosis                     Kidney Infection             TMJ
Rate the Stress Levels in Your Life Currently

        1 2 3 4 5 6 7 8 9 10

        low              high

Work Stress Level ___________ Personal Stress Level _____________ Relationships ________

Children ________ Spouse/Partner _______

Do You Have any Conditions That You Would Like to Bring to My Attention__________________

                                Polarity Health Client Release Form

I __________________________________, understand that the Polarity Energy Balancing
Therapy given here is for the purpose of promoting relaxation, increased energy flow, clarity, and
health-building balanced energy.

I understand that the Polarity Health Education is for health individuals who are taking
responsibility for health maintenance and health enhancement.

I understand that the Polarity Therapist does not diagnosis illness, disease or any physical or
mental disorder.

I understand that the Polarity Therapist does not prescribe medical treatment or perform spinal

I has been made clear to me that Polarity Therapy is not a substitute for medical examinations
and/or diagnosis and is recommended that I see and acupuncturist, chiropractor, physician, or
psychotherapist for any physical or mental illness, condition, or disease.

Client Signature _______________________________ Date ___________________

Practitioner Signature ___________________________ Date ___________________

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