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Six Alchemy

Confidential Client Case History + Intake Form

Birthday

In the space below, please list your current symptoms:

Please grade your current symptoms with 1- 'hardly noticeable' to 10 - 'symptoms are unbearable':

Please list any significant accidents/injuries/operations past and/or present:

Please use the space below to list any medications/vitamin supplements that you are currently taking:

Please check the box below if you have currently, or have had in the past any of the following health conditions:

Current + Past Health Conditions

Please use the space below if you are experiencing any other physical or emotional symptoms:

Please describe what you would like to accomplish from your sessions with Six Alchemy:

 Reiki + Holistic Wellness 

 

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