CONSULTATION FORM

All information given will be treated as confidential.

Name *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone

Email *

Birth date

Marital Status

Who do you live with?

Do you have children?

Profession

Please indicate below that you consent to treatment

I confirm that I request treatment using flower and vibrational medicine

Signed

Clear Signature

Date

What is your main reason for wanting to take flower essences? Set an Intention for the session what do you need now.

MIND/BODY SYMPTOMS ASSESSMENT

What are your physical symptoms (if any) and when did they begin?

How are your current energy levels?

How was your health as a child?

What about health problems in your family, especially your parents?

Please note any operations, injuries or accidents

Are you aware of any pain or tight muscles in any part of your body? If yes where?

Do you have headaches?

Are your hands usually cold or warm?

Are your legs usually cold or warm?

When your hands and feet are cold, what are you emotionally feeling?

WHAT DO YOU CONSIDER TO BE THE MOST TENSION PROVOKING PROBLEMS IN YOUR LIFE?

At home

In the workplace

Relationships (e.g. partner, children, friends, parents)

EMOTIONAL OVERVIEW

What problems in life do you have trouble dealing with today? Please consider the list below before answering

Anger
Lack of confidence
Irritability
Tearfulness
Decision making
Forgetfulness
Poor concentration
Confusion
Depression
Mood Swings
Night fears
Anxiety
Learning difficulties
Mental chatter

Please describe how you describe the emotions you have chosen. How do they manifest? What triggers this?

Do you have any childhood experiences that might have triggered these emotions? Who else in your family experiences these emotions?

Have you experienced any major emotional traumas or stress in your life? In the past year? In the past 5 years? (e.g. death of a loved one, divorce, money problems, chronic illness, job change)

HOW WOULD YOU LIKE FLOWER ESSENCES TO HELP YOU?

Please write a long-term goal for your flower essence work? (how would you like to feel in, say 6-12 months..........remember how you would like to feel)

Please look at the list below and tick anything that is appropriate to you , either at this time or in the past. Please also indicate immediate family if it feels appropriate.

General

Headaches
Migraine
Deafness/Hearing Difficulties Eyesight difficulties Insomnia
Loss of weight
Obesity
Dizziness
Fainting
Seizures
Epilepsy
Fatigue
Depression
Thyroid problems
Blurred vision
Allergies
Glaucoma
Panic/Anxiety attacks Depression
Hypoglycaemia
Candida
Diabetes

Cardiovascular

High/low blood pressure
Hardening of arteries
Angina
Rapid heart beat
Irregular heartbeat
Congestive heart failure
Swelling of the ankles
Poor circulation
Reynaud’s

Respiratory

Shortness of breath
Chronic cough
Vomiting blood
TB
Emphysema
Bronchitis

Women

Breast pain
Painful menstruation
Termination of pregnancy
Pelvic Inflammatory Disease
Polyps
Ovarian cysts
Menopause
Endometriosis
Difficulties conceiving
Miscarriage

Muscle and Joint

Arthritis
Low back pain
Neck Pain

Gastro-Intestinal

Colitis
Constipation
Crohn’s Disease
Diverticulitis
Gall Bladder
Haemorrhoids
Liver problems
Cirrhosis
Rectal bleeding
Irritable Bowel

Skin

Easily bruised
Dryness
Itching
Rash
Acne
Psoriasis
Eczema

Genito-Urinary

Kidney problems or failure
Painful urination/cystitis
Prostate problems

Intentions for Healing of mind, body and soul

Nurture Your Soul with Flower Essences

All information given will be treated as confidential.

MIND/BODY SYMPTOMS ASSESSMENT

WHAT DO YOU CONSIDER TO BE THE MOST TENSION PROVOKING PROBLEMS IN YOUR LIFE?

EMOTIONAL OVERVIEW

HOW WOULD YOU LIKE FLOWER ESSENCES TO HELP YOU?