Consultation

 

 

Functional Frequency Specific Microcurrent Intake form

What are your current health concerns?

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    • What course of treatments and action plan do you and your health team have in place?

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    • Are you accustomed to receiving bodywork, if so, what has been your experience?

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    Have you had any surgeries?__________________________________________________________________________________________________________________________

    Have you had any accidents?__________________________________________________________________________________________________________________________

  • Have you had any head trauma?__________________________________________________________________________________________________________________________
  • Have you had any sacrum trauma?__________________________________________________________________________________________________________________________
  • Were you born via c section?__________________________________________
  • Were you born via forceps?__________________________________________
  • Were you born via suction?__________________________________________
  • Are there any other significant events/traumas/experiences that have influenced you? Please state the event and your age.__________________________________________________________________________________________________________________________________________________________________
  •  Do you have diagnosed PTSD?__________________________________________Do you think you have undiagnosed PTSD?__________________________________________
  •  Are you taking medication? This is particularly important when it comes to Lymphatic Drainage. Please include product name and dosage.____________________________________________________________________________________

     

    Do you have any food or environmental allergies? Please state the substance and it’s effect on you. _________________________________________________________________________________

    Do you have any metal fillings, implants or pumps of any kind?

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Are you pregnant? Could you be pregnant?

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Are you on a nutritional plan or take supplements and or herbs?

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What is your activity level or exercise regime?

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What is your sleep pattern?

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What do you do to relax? What do you most enjoy?               __________________________________________________________________________________________________________________________________

Is there anything else about your medical and emotional history that you would like to share?

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I agree to receive treatment from Sarah Rotella.

Signature_________________________Date_________

  • Please email me your answers 24 hours prior to your appt., or if you wish you can bring them with you.
  • I also am open to working with your current team of health care providers with permission.