40 % ALL INFORMATION ON THIS PAGE IS STRICTLY CONFIDENTIAL Your Full Name: * Have you ever been diagnosed with a mental illness? * YES NO If yes, please explain: Have you been under regular medical or psychological treatment in the past year? * YES NO Paragraph Text Have you ever been treated for an emotional/behavioral problem? * YES NO If yes, please explain: Have you had or do you now suffer from any prolonged illness? * YES NO Paragraph Text List all current medications you are taking: * Please provide the name(s) and contact information of your current doctor(s) and/or therapist(s): By entering your name below, You give permission by Anthony M. Davis to contact Doctor(s) and/or Therapist(s) to ensure you receive full quality of care. Electronic Signature * Date * Electronic Signature: Guardian Date Have you previously or are you now suffering from any of the following Conditions? Check all that apply: * Anxiety Arthritis Asthma Cancer Diabetes Epilepsy Fainting Spells Fatigue Food Allergies Headaches Heart Condition High Blood Pressure Hypoglycemia IBS Overweight Spine or Back Problems Stress TMJ Ulcers Other If "Other" Provide Details: Are You Pregnant? YES NO Do You Drink Alcohol? * No Occasionally Moderately Daily Do You use Tobacco Products? * YES NO If YES, Check all that apply: Cigarettes Cigars Pipe Chewing Tobacco Snuff Other If "Other" Provide details: How much tobacco do you use per day? Do You Smoke Marijuana or use Recreational or other Drugs? * YES NO If "Yes" Provide type(s) and useage: How Many Hours Do You Sleep per Day on Average? * I, the undersigned, understand all questions and verify that all information is complete and accurate to the best of my knowledge. I also understand that the hypnotic methods used by Anthony M. Davis of Healing Hypnosis are not a substitute for medical or psychiatric treatment. I understand that during hypnosis, it may be necessary to touch my hand, arm, shoulder or forehead. I give permission to Anthony M. Davis of Healing Hypnosis and consent to do so in order to help me establish a beneficial state of hypnosis. I understand these methods to be a conditioning process, whereby an individual is taught to use their own abilities for their benefit and well being. With this understanding, I hereby grant the Anthony M. Davis of Healing Hypnosis permission to hypnotize me or the minor child whose name appears at the top of this form. I (we) further grant permission for the sessions to be recorded as needed. I know my progress is dependent upon my efforts and that there are no guarantees as to the result or progress to be made. I understand that the success of the hypnosis sessions will be in direct proportion to my commitment to the end result. By Entering my name below, I am confirming that all information is true to the best of my knowledge, and I agree to all the terms listed above: Electronic Signature * Date * Electronic Signature: Guardian Date ALL INFORMATION ON THIS PAGE IS STRICTLY CONFIDENTIAL If you are human, leave this field blank.
