Medical Qigong Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth Emergency Contact Medical History What is the primary reason you are seeking medical Qigong therapy? What mental or emotional stress do you experience now, or surrounding this issue? Have you ever been diagnosed with cancer? if so, please list date and specify. Have you had any recent surgeries or procedures? If so, please specify. Are you currently pregnant? Or trying to conceive? If you are menstruating, please describe any issues/pain you have around menstruation (if any). Are you currently taking any medications or supplements? If so, please specify. Qigong Experience Have you practiced Qigong before? If so, how long have you been practicing? Are you familiar with the principles of Qigong (breathing, movement, meditation)? What are your goals for incorporating Qigong into your wellness routine? Are there any specific areas of your health or well-being that you would like to focus on during your Qigong practice? Lifestyle Information Do you engage in regular physical exercise? If so, please specify. Do you practice any other forms of holistic healing or wellness practices (acupuncture, yoga, meditation, etc.)? Informed Consent I understand that the information provided on this intake form will be used to guide the prescription of Qigong exercises tailored to my individual needs. I agree to participate in the Qigong consultation with the understanding that the exercises prescribed are meant to enhance my overall well-being. I understand and agree that this is not a clinical counseling session. I acknowledge that this session is not medical advice, is not a replacement for a medical doctor, and that I should consult your primary care doctor prior to beginning any new exercises. Pricing and Cancellation Policy I acknowledge that the fee for each mentorship session is $260 US per hour and is non-refundable after the session commences. If I cancel the session within 24 hours of the scheduled time, a 50% fee will be deducted from my payment. If I cancel after 12 hours of the scheduled time, the full fee will be charged. Signature * Date * By typing my name above, I agree that this is my digital signature, and I agree to the above terms. Please note that this intake form is confidential and will be kept securely on file. Thank you for taking the time to provide this important information. Thank you!
