LymphWorks, LLC
2023 Energy Healing/Intuitive Coaching Intake Form
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Emergency Contact
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Medical Info
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Well Being
Sports
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Exercise
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Sugar Intake
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Flexibility
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Supplements
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Hobbies
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Water Intake
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Interests
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Mobility/Walking Aids
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Range of Motion
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Caffeine
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Salt Intake
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Are you currently taking any supplements/Natraceuticals?
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Infectious
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Pneumonia
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Strep
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Presence of any infectious condition?
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Treatment Goals
Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Substance Use Disorder
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Energy Level
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Chaotic
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Have you ever tested positive for COVID-19?
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Headaches
Rebound
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Sinus
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Tension
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Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Other Headaches
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Brain Disorders
Agoraphobia
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Bulimia Nervosa
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Schizophrenia
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Anorexia Nervosa
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Claustrophobia
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Sleep Disorder
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Antisocial Personality Disorder
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Depression
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Social Anxiety Disorder
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Anxiety
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Generalized Anxiety Disorder
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Asperger Syndrome
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Obsessive Compulsive Disorder
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Acute Stress Disorder
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Autism
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Obsessive Compulsive Personality Disorder
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ADD
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Bipolar Disorder
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Panic Disorder
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ADHD
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Borderline Personality Disorder
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PTSD
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Other Psychological
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Immune
CVID
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Sjogren's Syndrome
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HIV/Aids
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Hodgkin Lymphoma
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Infectious Mononucleosis
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Allergies
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Leukemia
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Anaphylaxis
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Lupus
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Cancer
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Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Other Immune
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Miscellaneous
Other Diagnosed Diseases
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Allergy
Sensitive to scents/essential oils
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Other Allergies
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Emotion / Mood
Depression
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Physical Abuse History
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Despair
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PTSD
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Rate the stress in your life (1-10)
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Grief
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Mental Abuse History
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Stress Response and Coping Strategies
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Negative Self-Talk
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Other Emotions
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Confusion
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Overall mood and energy level
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