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Health Record Form

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Personal Information

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Health Record Form

COVID-19 Safety Check

Thank you. We appreciate you sharing this with us. Your honesty keeps us all safe.

If you develop symptoms before your appointment, please call your practitioner. Please self isolate and contact AHS for testing.

We cannot see you in person if you have COVID-19 symptoms or are required to isolate or quarantine. We can reschedule, switch to a virtual appointment, or cancel your appointment with a full refund.

You must wear a mask while you're in our space to protect our most vulnerable clients and staff. Please bring your own water bottle, notebook, and pen.

We also wear masks during the appointment and we sanitize between clients. Please text your practitioner before you enter the space so we can stagger arrivals.

Your Physical Wellbeing

Do you have pain, injuries or any health issues in any of these parts of your body?

How are you? Thoughts, Experiences, Feelings, and Observations
What are you experiencing right now? Write down whatever comes to mind. Anything at all. It can be point form, whatever comes naturally.

Robins Holistic Stress Scale
Rate how much each of these stressors is affecting your experience RIGHT NOW. Include an event if you have been thinking about it today (even if it occurred many years ago). No need to dredge old stuff up, only include events that are active, on your mind, or affecting your emotional state. If you are worried about something, mark it as active and rate the intensity.

Answer quickly. Take your first response as accurate. No more than 5 seconds per question.

Please rate the mental or emotional intensity from 0 to 10.
0 = No. Not at all.
1 = Very Mild. (It doesn't really bother me.)
10 = Extreme. (It is all I can think about. I am an emotional mess right now because of this.)

Consent and Waiver

I understand that the Reiki or wellness session I receive is provided for the basic purpose of relaxation and stress reduction.

I further understand that the session should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified specialist for any mental or physical ailment I may be experiencing.

I understand that the therapist is not a medical doctor or a chiropractor and is not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such.

I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.

I affirm that I, as well as all members of my household, do not currently have nor have experienced COVID-19 symptoms within the last 14 days.

• I affirm that I, as well as all members of my household, have not been diagnosed with COVID- 19 within the last 14 days.

• I affirm that, to my knowledge, I have not been in contact with anyone who has been diagnosed with COVID-19.

• I affirm that if I travelled outside of Canada in the last month, I isolated in my home for 14 days upon my return.

• I understand that this business and my holistic health practitioner cannot be held liable should I experience exposure to the virus or any other contagion as a result of my providing misinformation on this form.

• I understand that, because Reiki and other natural health practices involve maintaining prolonged and close physical contact, there may be an elevated risk of disease transmission, including COVID-19.

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive a Reiki or wellness session.

May 11, 2021