DISTANCE APPOINTMENT QUESTIONNAIRE
By paying for a session with
Monica Levin I acknowledge the following:
1. Monica Levin is not a medical doctor and I am not here for medical
diagnostic or treatment procedures.
2. The services provided by Monica Levin are intended for general
well-being and do not involve the diagnosing, prognosticating, treatment, or
prescribing of remedies for treatment of any disease, or any licensed or
controlled act which may constitute the practice of medicine.
3. I am responsible for the continuation of my medical treatment and Monica
Levin does not recommend otherwise.
4. When it comes to Reconnective Healing and The Reconnection there are no
promises or guarantees and you may or may not feel or experience a healing.
INFORMATION MONICA MAY ASK FOR:
| Name | ______________________________________________________ |
| Address | ______________________________________________________ |
| Address (cont.) | ______________________________________________________ |
| City | ______________________________________________________ |
| State, Zip Code | ______________________________________________________ |
| Telephone | ______________________________________________________ |
| Cellular | ______________________________________________________ |
| ______________________________________________________ | |
| Age | ______________________________________________________ |
| Date of Birth | ______________________________________________________ |
| Occupations | ______________________________________________________ |
| ______________________________________________________ |
|
PHYSICAL SYMPTOMS |
Often |
Rarely |
Never |
| I have stiff joints | |||
| My muscles ache | |||
| My muscles cramp | |||
| My legs hurt at night | |||
| I have headaches | |||
| I have migraines | |||
| I have dry skin | |||
| I have eczema | |||
| I have psoriasis | |||
| I get other skin irritations | |||
| I feel tired | |||
| I do not sleep well | |||
| I need a nap during the day | |||
| I smoke | |||
| I have shortness of breath | |||
| I have a cold | |||
| I have a cough | |||
| I have flu | |||
| I have an earache | |||
| I have sinus congestion | |||
| I have a sore throat | |||
| I have heart burn | |||
| My intestines cramp | |||
| I have gas and bloating | |||
| I have constipation | |||
| I have diarrhea | |||
| I have blood in my stools | |||
| It hurts when I urinate | |||
|
Women: If I still menstruate: |
Often | Rarely | Never |
| I have menstrual cramps | |||
| My periods are irregular | |||
| I have premenstrual symptoms | |||
| My menstrual flow is | light | medium | heavy |
| If I have stopped menstruating: | |||
| I am on hormone replacement therapy | |||
| I have a dry and painful vagina | |||
| MENTAL/EMOTIONAL SYMPTOMS |
|||
| Thoughts keep going around in my head | |||
| I feel hyperactive | |||
| I cannot sit still | |||
| I have a hard time paying attention | |||
| My thoughts are foggy | |||
| It is hard for me to remember things | |||
| I feel moody | |||
| I feel depressed | |||
| I feel anxious | |||
| I behave differently depending on what I eat | |||
| FOOD AND DRINK | Often | Rarely | Never |
| artificial sweeteners | |||
| margarine | |||
| salt | |||
| sea salt | |||
| fried foods | |||
| regular pop (soft drinks) | |||
| diet pop (soft drinks) | |||
| coffee | |||
| regular tea | |||
| herbal tea | |||
| alcohol | |||
|
kinds: _________________________________________________________________ |
|||
| water | |||
|
I have had the
following operations: _________________________________________________________________________ _________________________________________________________________________ |
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|
I have received
diagnoses of the following from my medical doctors: _________________________________________________________________________ _________________________________________________________________________ |
|||
| I am currently taking medications prescribed to me by my medical doctor | |||
|
These medications
are: _________________________________________________________________________ _________________________________________________________________________ |
|||
|
and are for my: _________________________________________________________________________ _________________________________________________________________________ |
|||
| I am currently taking the following over the counter medications | |||
|
These medications
are: _________________________________________________________________________ |
|||
|
and are for my:
_________________________________________________________________________ |
|||
|
I am concerned about
the following
life situation: _________________________________________________________________________ _________________________________________________________________________ These are more issues that I would like clarity about: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ |
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