Test Intake - Harmonic Egg Ellipse®

Check conditions listed below which you have experienced: Use P for over a year ago, C for current

Heigh/Low Blood Pressure

Problems with periods

Any recent substance Injection under skin

Difficulty starting Urination

Urinary Incontinence

Blood Clots/Phlebitis

Difficulty Swallowing

Numbness or Tingling

Past Viral Infections

Medications, Herbs, Supplements (list name, dose, and purpose)

We recommend drinking 2.5 - 3.5 liters of water daily starting on the day before your first session and for the days of integration.

Do you expect any difficulty with this?

Yes No

How much do you use per week?

Injuries/Accidents?

Yes No

Traumatic life events leading to any illness:

Describe other medical conditions that we should be aware of:

Areas in body of complaint or tension:

Surgeries with dates (include location of metal plates/rods/screws)

Family midical history

Current Pain Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Current Stress Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Current Energy Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Describe any specific medical attention or assistance you will need while visiting our center (you must be able to get into the unit or bring a caregiver to help you).

Will you be bringing a caregiver, nurse or spouse with you?

Please select the checkbox of the word that best describes your current state of health:

What brings you joy?

Please check the box of the most emotional draining relationship or relationship in your life:

Is your home environment peaceful or stressful most of the time?

Do you have trouble concentrating, or ‘brain fog’?

Yes No

Do you feel supported?

Yes No

What drives you, inspires you, gives you a sense of purpose:

Please check the emotions that best reflect how you feel most of the time:

Do you adhere to any particular diet?

How many hours of sleep do you get on average?

Do you drink filtered or purified water?

Yes No

Describe your exercise/activity routine:

Are you sensitive to light / loud noise?

Yes No

If Yes, Please explain:

Are you in fear regarding your health?

Regaining well being requires a strong personal commitment. How ready are you to make the lifestyle changes, the diet changes and the attitude changes that may be necessary to good health?

Ready Somewhat Not looking to make changes

I have read the above information and have filled out the form to the best of my knowledge. I understand that the questions on this form are being asked in order to better access my current circumstances and their relationship to my well-being. I further understand that I am voluntarily agreeing to have a relaxation therapy session and that no medical claims or promises of healing have been given.

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Check conditions listed below which you have experienced: Use P for over a year ago, C for current