Reiki Roland Bérard

This intake form will be sent by internet once you have completed it and filled out the consents. This will give Mr. Bérard the opportunity to get to read it before your RV and will save a lot of time at the first session. Once it has been sent, you will receive a copy by email.

Manual option - .pdf form

However, if you absolutely do not want to fill out a form that will be sent by internet or you have problems filing it out, you can choose the option of filling out a .pdf form, print it and take it with you to your first session.
Click here to access this form.

(233ko)

Date : 9/3/2010
Mailing list:	Yes	No

Last name:

First name:

Address:

City:

Province/State:

Country:

Postal code:

Phone:

Home:
Office:
Cellular:

Occupation:

E-mail:

Emergency contact:

Name:

Phone:

Birth date:
Age:
Height:
Weight:
Relationship status:
No. of children:
Ages:
Refered by:
Physician:	Name:	Phone:
Therapist:	Name:	Phone:

Reason for the visit: (max. 400 characters)
Start date of symptoms:
Past / present treatments: (For reason for visit) (max. 400 characters)
Current medication: (max. 400 characters)
Supplements: (max. 400 characters)
Complimentary therapies: (max. 400 characters)
Eating habits / diet: (max. 400 characters)

Daily intake: (unit)

Water

Caffeine

Alcohol

Cigarette/Tabaco

Exercise routine:
(max. 400 characters)

Vision:

Glasses / contact lenses:

Smell:

Hearing:

Taste:

Emotional / Psychological

Depression		Eating disorder
Mood swings		Substance abuse
Explanation (if needed) (max. 400 characters)

Auto-immune (type)

AIDS / HIV	Lymes disease
Allergies	Mononucleosis	Type
Fatigue	Cancer (Type)
Fever (chronic)	Herpes (Type)
Fibromyalgia	Fungal infections (Type)
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	Type
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 (chronic)		Jaundice
Diabetes		Liver disorder
Diarrhea (chronic)		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	Type	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

(Further details on reason for visit or anything else you want to share or want me to know)
(max. 400 characters)