New Client Questionnaire

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Thank you for taking the time to fill out the form below.

Please take time to complete this form and give as much detail as possible, so that your health practitioner can understand you better and provide a high level of care.

E-mailadres *

Illuma Health HQ Operating hours are Monday - Friday 10 am- 6 pm [Closed on Public Holidays]

Illuma Health Satellite Operating hours varies at Lavendar

Name [First & Last] *

Phone [For us to schedule appointments with you via whatsapp.] *

Home Address [This is part of what we need in collection of particulars, so there is no need to fill up a physical form when you are here.] *

Date of Birth [DD|MM|YYYY) *

Marital Status *

Single

Married

Divorced

Widowed

Other

Current Occupation *

Acknowledgement *

I understand the importance of filling up this form.

Verplicht

Do you feel happy at work? Do you feel happy at home? *

What makes you happy? *

Did you have a happy childhood? Why? *

Why are you seeking somatic therapy for yourself? *

Prior interventions? * [Have you experienced any form of complementary or alternative treatment before? Have you ever used prayer, meditation, mindfulness or spiritual practice to facilitate your health journey?] *

Are you currently experiencing any of the following? Check all that apply. *

Nervousness

Inability to relax

Sleeplessness

Mood imbalances

Nail biting

Nightmares

Tantrums / Meltdowns

Compulsive tendencies

Teeth grinding

Poor health

Physical pain

Unexplained bouts of fear

Overeating / Undereating

Serious eating disorder

Self-mutilation

Co-dependency

Inability to focus

Poor memory

Social difficulty

Recent divorce of parents

Childhood trauma

Illness or death of loved one

Lack of energy

Low self-esteem

ADD / ADHD

Abusive home situation

Anders:

Verplicht

Are you getting medical attention? If so, who are your doctors/specialists? *

Are you on any medications? If so, which ones? *

Any background of abuse? [Have you ever experienced physical or emotional abuse? This may include hitting or other unwanted physical contact, yelling or name calling. This may include sexual abuse, even if circumstances may cast doubt on it. If you feel safe to, please provide some basic details.] *

How did you hear about Illuma Health Clinic? [If referral please provide referral name in 'other' column] *

Google search

Instagram

Facebook

Referral

Anders:

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Informed Consent and Liability Waiver: https://drive.google.com/file/d/17zOW8756htSHJRmEpAHHwf2TlliiBJvW/view?usp=sharing

Informed Consent and Liability Waiver *

I have read and agreed to the Informed Consent and Liability Waiver.

Verplicht

Would you like to receive information and updates from Illuma Health and associated partners? *