Psychotherapy & Energy Healing by Enrique Arellano Farias
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Contact Information
Name:
Date of Birth:
Email:
Address:
City:
Postal Code:
Home Phone:
Work Phone:
Emergency Contact:
Phisical Info
Height:
Width:
Vision:
Wear glasses / Contact:
Smell:
Hearing:
Taste:
Relationships
Relationship Status:
Ages:
Referred By:
Other Treatments / Therapy information
Physician (name & phone):
Therapist (name & phone):
Reason for visit:
Date of Onset:
Current / Previous Treatment:
Current Medications:
Date of Onset:
Current Complementary Therapies:
Personal Habits
Eating Habits / Diet:
Water Intake:
Caffeine Intake:
Cigarette / Tobaco:
Exercise Routine:
Emotional / Psychological
Depression:
Eating disorder:
Mood swings:
Substance abuse:
Explanation

(if needed, max. 400 characters)
Auto-immune (type)
AIDS / HIV
Lymes disease
Allergies
Mononucleosis
Fatigue
Cancer (Type)
Fever (chronic)
Herpes (Type)
Fibromyalgia
Fungal infections
Explanation
(if needed, max. 400 characters)
Endocrine
Adrenal Insufficiency
Hyperthyroid
Pituitary dysfunction
Hypothyroid
Explanation
(if needed, max. 400 characters)
Neurological (type)
Epilepsy
Insomnia
Dizziness
Migraines
Explanation
(if needed, max. 400 characters)
Musculo-Skeletal
Arthritis
Carpal tunnel
Rheumatism
Gout
Back pain
Skin disorder
Explanation
(if needed, max. 400 characters)
Ear / Nose / Throat
Earaches (Chronic)
Jaw pain
Headaches
Explanation
(if needed, max. 400 characters)
Cardio-vascular
Angina
Hypertension
Heart attack
Stroke
Heart failure
Explanation
(if needed, max. 400 characters)
Respiratory
Bronchitis
Tuberculosis
Pneumonia / Pleurisy
Explanation
(if needed, max. 400 characters)
Digestion
Constipation
Jaundice
Diabetes
Liver disorder
Diarrhea
Ulcers
Gastritis
Flattulance
Hepatitis
Pancreas
Hypoglycemia
Explanation
(if needed, max. 400 characters)
Urinary
Bladder infection
Kidney stones
Explanation
(if needed, max. 400 characters)
Reproductive
Sexually Trans.
Disease (type)
Miscarriages
Endometriosis
Abortion
Pregnancies (# & C)
Explanation
(if needed, max. 400 characters)
Major Illnesses
Chicken pox
Mumps
Measles
Whooping cough
German measles
Scarlet Fever
Explanation
(if needed, max. 400 characters)
Others
Explanation
(if needed, max. 400 characters)
Please list any injuries you had and have presently:
(max. 400 characters)
Please list any surgeries you had or know you will have :
(max. 400 characters)
Please list any traumatic, or life treatening events that
occurred in your life, and when they happened:
(Ex.: Separation, divorce, depression, deaths or other significant event)
(max. 400 characters)
What do you hope for and what are your expectations
from this healing today and long-term:
(max. 400 characters)
What is your connection with spirituality:
(religious background, current practice, development)
(max. 400 characters)
Brothers / Sisters:
Rank in family:
Relationship with mother
As a child
(max. 400 characters)
Present
(max. 400 characters)
Relationship with father
As a child
(max. 400 characters)
Present
(max. 400 characters)
General
(max. 400 characters)