DISTANCE APPOINTMENT QUESTIONNAIRE

Print and complete this form before your appointment with Monica Levin 248 656 2505.

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By paying for a session with Monica Levin I acknowledge the following: 
1.  Monica Levin is not a medical doctor and I am not here for medical diagnostic or treatment procedures.
2.  The services provided by Monica Levin are intended for general well-being and do not involve the diagnosing, prognosticating, treatment, or prescribing of remedies for treatment of any disease, or any licensed or controlled act which may constitute the practice of medicine.
3.  I am responsible for the continuation of my medical treatment and Monica Levin does not recommend otherwise.
4.  When it comes to Reconnective Healing and The Reconnection there are no promises or guarantees and you may or may not feel or experience a healing.

INFORMATION MONICA MAY ASK FOR:

Name     ______________________________________________________
Address     ______________________________________________________
Address (cont.) ______________________________________________________
City ______________________________________________________
State, Zip Code ______________________________________________________
Telephone ______________________________________________________
Cellular ______________________________________________________
Email ______________________________________________________
Age ______________________________________________________
Date of Birth ______________________________________________________
Occupations ______________________________________________________
  ______________________________________________________
 
PHYSICAL SYMPTOMS		  
Often
Rarely 		 
Never
I have stiff joints
My muscles ache
My muscles cramp
My legs hurt at night
I have headaches
I have migraines
I have dry skin
I have eczema
I have psoriasis
I get other skin irritations
I feel tired
I do not sleep well
I need a nap during the day
I smoke
I have shortness of breath
I have a cold
I have a cough
I have flu
I have an earache
I have sinus congestion
I have a sore throat
I have heart burn
My intestines cramp
I have gas and bloating
I have constipation
I have diarrhea
I have blood in my stools
It hurts when I urinate
 
Women:
 If I still menstruate:		 Often Rarely Never
I have menstrual cramps
My periods are irregular
I have premenstrual symptoms
My menstrual flow is    light    medium    heavy
If I have stopped menstruating:      
I am on hormone replacement therapy
I have a dry and painful vagina
 
 MENTAL/EMOTIONAL SYMPTOMS		    
Thoughts keep going around in my head
I feel hyperactive
I cannot sit still
I have a hard time paying attention
My thoughts are foggy
It is hard for me to remember things
I feel moody
I feel depressed
I feel anxious
I behave differently depending on what I eat
 
FOOD AND DRINK Often Rarely Never
artificial sweeteners
margarine
salt
sea salt
fried foods
regular pop (soft drinks)
diet pop (soft drinks)
coffee
regular tea
herbal tea
alcohol
 
kinds:  _________________________________________________________________
water
       
I have had the following operations:

_________________________________________________________________________

_________________________________________________________________________
I have received diagnoses of the following from my medical doctors:

_________________________________________________________________________

_________________________________________________________________________
I am currently taking medications prescribed to me by my medical doctor
These medications are:

_________________________________________________________________________

_________________________________________________________________________
and are for my:

_________________________________________________________________________

_________________________________________________________________________
I am currently taking the following over the counter medications
These medications are:

_________________________________________________________________________
and are for my:

_________________________________________________________________________
 
I am concerned about the following life situation:

 _________________________________________________________________________

 _________________________________________________________________________
 
 
These are more issues that I would like clarity about:

 _________________________________________________________________________

 _________________________________________________________________________

 _________________________________________________________________________

 _________________________________________________________________________


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