1. Please give complete history: medical, mental, emotional, spiritual. Include accidents, traumas, operations, chronic & acute pains & conditions. Please list present conditions and medications. Use time line to help you remember:
Birth to 10
2. Describe your extended family, parents, siblings, spouse, children, their health, and how they relate to the above:
3. Describe your life style. What are your habits? What can you not do without(addictive behavior)? How do you take care of yourself?
4. Describe your stresses and where you feel them in your body. Describe your connection to your body, your body image, pains discomforts, joys, frustrations.
5. What are your goals generally & for this session/training?
ACUPRESSURE CONSENT FORM Acupressure is a self care modality, not a medical procedure. It is utilized completely at your own risk and discretion. Please notify the instructor and seek permission from your medical care provider in the following special circumstances: pregnancy, serious disease, pacemaker, contagious disease.
Avoid pressing on or applying ear beads to irritated skin, open sores or recent wounds. You will sometimes be finding points on yourself. We will be working over your clothes and there should be no skin irritation, only possible mild fleeting discomfort when locating a `reactive’ point.
Please tell me if you are pregnant as there are specific points, good to support childbirth, which should be avoided in pregnancy.
In signing this consent form, you legally release the instructor, Esther McCormick and the Mercy Center from all responsibility relative to your participation in this class/ session and accept full responsibility for any reactions to procedures that result from your participation.
Please leave your telephone number &/or email address, if you are interested in receiving information in the future. No information about you will be shared with others outside of this center, for any reason, period! We respect your privacy.
Please check here if you would like to discuss a series of sessions at our special discount_