Intake Form - Essential Healing with Dr. Liz
Please answer each of the questions provided and click submit on the bottom of the form.

Wishing You GREAT health! - Dr. Liz

Email address *
First & Last Name: *
Your answer
Today's Date: *
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Address: City: State: Zip/Postal Code *
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Phone: *
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Birth date: *
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Whom may I thank for referring you?
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Have you experienced Healing Touch, EFT, Emotion Code or other energy therapy before? *
Living situation: Check All That Apply *
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Number of children: *
Occupation: *
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Are you under the care of a doctor, psychotherapist, counselor or other health care practitioner at this time? *
If so, please list name(s) and phone number(s):
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Are you currently taking any medications? *
If yes, what?
Your answer
Have you had any illnesses, injuries, trauma, or surgeries that may be affecting your health now? *
If so, please describe:
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Are you currently experiencing any symptoms (pain, tension, anxiety, etc)? *
If so, please describe:
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How does this affect your daily activities (sleep, exercise, decision-making, relationships)?
Your answer
For each symptoms/concerns below that apply to you, please rate your distress level for each using the scale below each:
Your answer
Depression *
None
Maximum
Mood Swings *
None
Maximum
Anger *
None
Maximum
Alcohol/Drug Use *
None
Maximum
Sleep problems *
None
Maximum
Anxiety *
None
Maximum
Panic attacks *
None
Maximum
Memory problems *
None
Maximum
Eating problems *
None
Maximum
Hormonal imbalances *
None
Maximum
Allergies *
None
Maximum
Stress (home) *
None
Maximum
Stress (work) *
None
Maximum
Religious/spiritual practice:
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What is your desired outcome for today’s session? *
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What are your long term health goals? *
Your answer
In case of emergency, I authorize Dr. Liz Winders to contact: Name & Phone Number *
Your answer
Anything else I should know? Questions?
Your answer
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