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HILTON HEAD HEALING ARTS INTAKE FORM 

Date:  
E-mail:  
Name:  
Address:  
 City:  
State:  
Zip:  
Phone(s):   
Fax:  
Date of Birth:  
Occupation:  
Please take some time to read all the questions before you complete this form and give yourself as much time as you need to find the answers.

Important others (living situation):

Other health care providers involved in your care:

Medications, herbs, vitamins, supplements you are currently taking:

What is your best time of day? Why?   Your poorest time of day?  Why?

Reason for seeking healing (presenting complaint):

Specific past and present physical information:

Specific past and present emotional information:

Specific past and present mental information:

Specific past and present spiritual information:

Doing a life review, what has been the worst for you?

Doing a life review, what has been the best for you?

Any other situations or facts you feel are pertinent?

Thank you for taking the time to complete this form thoughtfully.  I will use this information to help plan our first visit together.

Below is a link that will send this form directly to Carol Tietjen. Upon selecting this link, you will be taken to a printable page, so that you may print this information out for your own records. Select the logo to take you back to the scheduling and fees page so that you may fill out any remaining forms that require your attention.