Bienvenue chez ArteZen Vibrational Wellness

Johanne Pelletier
Praticien certifié en énergie

First name

Last name

Birthday

Jour

Mois

Année

Phone

Address

Emergency Contact Name and Phone Number

Name and Phone Number of your Family Doctor

PLEASE READ CAREFULLY:

I understand that the sessions I receive at ArteZen Vibrational Wellness, including Infinite Energy Method™ sessions, chakra alignment, meridian balancing, biofield work, and other energy modalities, are provided for the purpose of supporting my body, mind, and energy system. If I experience any discomfort during a session, I will immediately inform my practitioner.

I further understand that these sessions are not a substitute for medical care, diagnosis, or treatment, and I am responsible for consulting a qualified healthcare provider for any medical concerns. Energy work may support physical, emotional, or energetic balance, but results can vary from person to person.

I consent to the storage of my submitted information for the purpose of reviewing it in relation to my sessions. By typing my name below, I agree to these terms, affirm that my information is accurate, and authorize this as my electronic signature.

I consent to having this website store my submitted information for 60 days so that it can be reviewed by ArteZen Vibrational Wellness

Please type your full name

Date

Enter today's date

How did you find ArteZen Vibrational Wellness? Referral / Google / Word-of-mouth / Instagram / Other *

What do you hope to gain from your session?

Describe problems you wish to address. Include how long you have had them, any medical diagnoses for them, treatments you have tried, and their effectiveness.

Do you have a Pacemaker?

Yes

Do you have any Metal Plates, Rods, Screws or Pins?

Yes

Do you have Diabetes?

Yes

If female, are you pregnant? Or trying to become pregnant?

Yes

List any surgeries that you feel are relevant

List any major accidents, or traumatic events that you feel are relevant

Allergies (drugs, chemicals, foods, airborne allergies, etc)

Current Pharmaceutical Medication

List all medications you take, and what they have been prescribed for.

Supplement

List all nutritional and herbal supplements you take. This is very important for body sessions.

Alcohol consumption

How often do you drink alcohol? Per day, or per week, or per month.

If yes, when was the last time you had a drink?

Coffee and Caffeine

How often do you drink Coffee (including Lattes, Cappucino, caffeinated Teas) Per day, per week, or per month,

If yes, when was the last time you drank coffee?

Pop

How much pop do you drink? Per day, per week or per month.

Smoking

If you smoke, how many times do you smoke per day or per week?

List any recreational drugs and how often you use them.

When was the last time you used this substance?

Do you experience stress?

Extreme Stress

Moderate Stress

Low Stress

How do you deal with stress?

What do you do to relax?

What do you do to take care of your physical body?

Are there any other issues or topics you would like to discuss?

Thank you very much for completing the intake form. I look forward to discussing your comments during your consultation. Please ensure that you receive a "sent" notification before exiting the form.