Your Name
*
First Name
Last Name
Mobile Number
(###)
###
####
Email Address
*
Program & Service Name
Bio-Energetic Aromatherapy
Bio-Energy Vibrational Tuning
Access Bars
Access Energetic Facelift
Access Bars Class
Consultation/Coaching
Which session is this progress report for?
II (2)
III (3)
IV (4)
V (5)
VI (6)
VII (7)
VIII (8)
IX (9)
X (10)
Date of Your Next Appointment
MM
DD
YYYY
Time of Your Next Appointment
Hour
Minute
Second
AM
PM
Depression
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Mood Swings
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Anger
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Alcohol/Drug Use
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Sleep Problems
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Anxiety
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Panic Attack
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Memory Problems
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Eating Problems
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Hormonal Imbalance
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Allergies
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Work-Related Stress
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Home-Related Stress
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Other
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Other
0 Non-Existence
1
2
3
4
5
6
7
8
9
10 Maximum Pain/Distress
Any changes with the medications you are taking since last session?
No
Yes
If Yes, please list:
Any new illnesses, injuries, trauma or surgeries that may be affecting your health since your last session?
No
Yes
If Yes, please explain:
Are there any new symptoms (pain, tension, anxiety, etc.) since your last session?
No
Yes
If yes, please explain:
Anything new that is impacting your daily activities (sleep, exercise, decision-making, relationships)?
No
Yes
If yes, please explain:
What has been difference in your experience from your everyday since our last session?
Anything else you would like add/update us?
What is your intention and desired outcomes for today’s session?
Is your long-term health goals still remain the same? What is it for you now?
New Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
New Phone Number
(###)
###
####
New Emergency Contact
First Name
Last Name
New Emergency Contact Number
(###)
###
####
