Pre-appointment Health Questionnaire

Please complete and submit before your first appointment.

Your wellbeing is important.  To give you the most appropriate and beneficial complimentary therapy experience it is necessary gather relevant health information about you before starting your appointment.

Pre-appointment Health Questionnaire

Client Information

Name
Name
First Name
Last Name

Please circle the answer
to the following questions
Are you / Have you:

Epileptic?
Pregnant?
Heart conditions?
Have a pace maker?
Have any joint replacements?
Medicated for psychosis?
Low / high blood pressure?
Have symptoms of Thrombosis
Recovering from an accident?
Fibromyalgia?
Medicated for inflammation?

Receiving treatment for
any serious medical illnesses
eg. cancer

Had a stroke?
Had symptoms of stroke?
Bipolar?
Anxiety?
Depression?
Nervous disorders?
A seriously dysfunctional family?
A complex background?
Eating / Food disorders?
Had surgery recently?
In good health?

Disclaimer:

I am aware Aura Photography, Sound, Music, Ascension Energy appointments and Coaching are intended as a natural therapy & it does not replace prescribed medicines for ailments best diagnosed by a qualified medical doctor.
I am aware Aura Photography, Sound, Music, Ascension Energy appointments and Coaching are intended as a natural therapy & it does not replace prescribed medicines for ailments best diagnosed by a qualified medical doctor.
I understand Inner Tranquillity & Peace does not diagnose illnesses and I will consult a qualified medical doctor for any symptoms of illness or concerns.
I understand Inner Tranquillity & Peace does not diagnose illnesses and I will consult a qualified medical doctor for any symptoms of illness or concerns.
I waive Julia Smith of any and all liabilities. I take responsibility to undertake appointments as my own choice at my own risk. I understand I best know my own body and its limitations.
I waive Julia Smith of any and all liabilities. I take responsibility to undertake appointments as my own choice at my own risk. I understand I best know my own body and its limitations.
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