Crystal Therapy Benefits A Typical Session Biography Location Appointment
Crystal Therapy ; Health History Form
Name ___________________________________________ Date of visit___________________
Address _________________________________ City____________, State______Zip_________
Occupation ______________________________________________________________________
Telephone _______________________________ Email __________________________________
Referred by ______________________________________________________________________
What is your previous experience with crystals & energy work?
________________________________________________________________________________
Do you meditate? Yes No
Do you practice yoga? Yes No
Do you have any chronic, hereditary, congenital problems? Yes No
If yes, please describe_________________________________________________________________
Where in your body are weak or vulnerable areas?
___________________________________________________________________________________
What are your primary areas of pain?
___________________________________________________________________________________
Have you had counseling before? Yes No
What is your most volatile or vulnerable emotion?
__________________________________________________________________________________
What emotion do you least express? Yes No
Do you have any difficulties laying on your back? Yes No
Are you allergic to fragrances of essential oils? Yes No
If yes, please describe_______________________________________________________________
Do you perform any repetitive movement in your work or hobby? Yes No
If yes, please describe_________________________________________________________________
Do you site for long hours at a workstation or computer? Yes No
If yes, please describe _________________________________________________________________
Are you under medical supervision? Yes No
Are you currently taking medication? Yes No
If yes, please list__________________________________________________________________
Summarize what you want to work on in the crystal healing session, including the spiritual, emotional, mental and physical concerns.