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Health History

This interview allows you to get the best value from your first session.

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Question 1 of 39

First Name

Question 2 of 39

Last Name

Question 3 of 39

Email

Question 4 of 39

Phone:

Question 5 of 39

Website

Question 6 of 39

Gender: M F Other

Question 7 of 39

City/Town

Question 8 of 39

Province/State

Question 9 of 39

Country

Question 10 of 39

Terms and conditions of service:
I am representing myself and no other body or agency.

I understand that Nelda McEwen is not a medical doctor and does not diagnose or treat disease.

I understand that consultations by Nelda McEwen is assessed at an energy/frequency level.

 My agreement is voluntary and I am not under any duress to agree with these terms.

A

Yes

B

No

Question 11 of 39

Appointment Agreement:

I agree to meet with Nelda McEwen at the agreed upon time and the agreed upon way; By phone, Skype, or in person. I promise to honour this appointment.
If by phone I will be responsible for all phone charges.

I understand that I will be invoiced for all agreed upon charges by Nelda McEwen. I understand that financial renumberations is expected in exchange for Nelda McEwen's time and expertise.

The Vital Energy Assessment is paid upon at the time of invoice. Payment can be by: E-transfer, money transfer, Stripe, or PayPal. 

I understand that payment is due upon receipt of goods and/or service.

Cancellation of appointments will be done by phone/voice mail at least 24 hours in advance.

I understand I will be charged a one hour fee for a missed appointment.

(Select all that apply)
A

I agree

Question 12 of 39

My appointment is:

A

In Person

B

By Phone

C

By Skype

D

Combination of in-person and distance follow op

Question 13 of 39

How old are you (we grow in 7 year cycles; physically and spiritually.

Question 14 of 39

Where were you born? Where were you raised? Are you a city mouse or a country mouse? What is your ethnicity/race/tribe?

Question 15 of 39

Did you have any health episodes growing up? Any repeated complaints? Any accidents? Any childhood illnesses?

Question 16 of 39

Any antibiotic use? Why?

Question 17 of 39

What do you do for a livelihood? Any stressed with the job? Toxins or technology exposure of note? Physical demands?

Question 18 of 39

Any significant dental? Grey filings? Root canals? Braces? Other?

Question 19 of 39

What medications have you/are you taking? What are they treating?

Don't name them; just what are they for.

Question 20 of 39

Are you or your partner on birth control pills? In the past?

Question 21 of 39

Blood Type:

A

B

AB

O

Vampire

Alien

A

A

B

B

C

AB

D

O

E

Vampire

F

Alien

Question 22 of 39

Do you feel worse when:

(Select all that apply)
A

Changes of season or in a season?

B

Changes of barometric pressure?

C

Moving indoors/outdoors?

D

Moon Phases?

E

Around other people or in crowds?

Question 23 of 39

Have you had Childhood vaccinations?

Question 24 of 39

Any vaccines in adulthood?

Question 25 of 39

Have you received any of the new mRNA vaccines?

Question 26 of 39

Have you experienced any known side effects or changes in your health overall?

Question 27 of 39

Do you eat:

(Select all that apply)
A

Dairy foods

B

Wheat

C

Breads/Baked goods

D

Corn/Corn Products

E

Eggs

F

Coffee

G

Chocolate

H

Alcohol/beer/wine

I

Deep fried foods

J

Candy/sweets

K

Hydrogenated oils

L

Do you use tobacco?

Question 28 of 39

Are there any other stresses that could affect your health and well being?

Personal Life

Are there life issues or personal issues you wish you could change?

Question 30 of 39

Are you in a committed relationship? Do you wish you were? Or wish you were not?

Question 31 of 39

Is there anything keeping you from being the most authentic or vital you?

Do others hold you back? Do you hold yourself back?

Question 32 of 39

Are you fulfilled in your work or at work? Do you feel like you are in touch with your life purpose?

Question 33 of 39

Do you enjoy the people you work with? Do you enjoy the people you live with?

Question 34 of 39

Do you express yourself creatively? Do you have a hobby, game, passtime, or sport that you enjoy and fulfills you? What do you enjoy doing?

Are you able to devote some quality time to do so?

Question 35 of 39

What rules do you follow that you wish you could break?

Question 36 of 39

What other types of health services do you use? What other caregivers are on your team?

Question 37 of 39

What is your SUPERPOWER?

(Clue: something about yourself you take for granted because it comes easy for you).

Question 38 of 39

What is your Kryptonite? (what situation, substance, circumstance weakens you?)

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