NEW CLIENT MEDICAL INTAKE FORM Name * First Name Last Name Email * EMERGENCY CONTACT NAME AND PHONE NUMBER * Do you have any of the following' * It is contraindicated to have Reiki if you have a Pacemaker. Reiki can alter your heartbeat. If you have Insulin Dependent Diabetes, Reiki can change the amount of insulin needed and you will need to check your insulin more often. Reiki energy has heat associated with it and can hinder the healing of serious burns. No Pacemaker Insulin Dependent Diabetes Second or Third Degree Burns that are in the healing stage Are you under under the care of a physician? Yes No What condition or conditions are you being treated for? Are these conditions new or have you had them for over a year? Do you have any injuries or areas that are painful to be touched? I will hover over this areas instead of touching them if they are where I am working. Yes No When did this happen? MM DD YYYY Please describe Injury Are there any Emotional concerns that you would like me to be aware of? Mental Health issues, relationship problems, etc. Thank you! New Client Reiki Form
