Application - Olana

CHOIX DE PARCOURS

3 Months Discovery - Pay in full - 899$
3 Months Discovery - Payment plan - 995$ / 3 months
6 Months Transformation - Pay in full - 1795$
6 Months Transformation - Payment plan - 1995$ / 6 months

Name

First

Last

Age

Date of birth (DD/MM/YYYY)

Phone number

Email

Full address

Emergency contact (First name, last name, phone number & relationship)

Place of birth :

Profession :

Referred by:

Reason(s) for consultation

To the best of your knowledge, do you know the cause(s)?

Yes
No

If yes, which one?

Have you received one or more diagnoses from certified professional(s)?

Yes
No

Purpose(s) of consultation

I invite you to take a break. Close your eyes, inhale deeply and exhale completely. Take a moment to take stock of how you're feeling. How are your physical and emotional bodies? What space do your thoughts occupy? Share how you're doing in a few sentences. Then, on a scale from 0 to 5 (5 = very present), indicate where the various health factors described below currently stand.

Physical activity

Stress level

Sleep quality

Interpersonal life

Sex life

Inner life (or spiritual life)

Joy of living

Morning energy

Intolerance or allergies?

Food intolerance(s)
Food allergie(s)
Drug allergie(s)
Pet allergie(s)

If you checked one or several answers, add details here

Food philosophy

Are you prone to anxiety (with or without panic attacks)?

Yes
No
In the past

Have you been diagnosed with cancer?

Yes
No
In the past

Have you ever experienced uncontrollable muscle contractions or been diagnosed with epilepsy?

Yes
No
In the past

Do you own an epipen?

Yes
No
In the past

Are you suffering from glaucoma?

Yes
No
In the past

Are you pregnant or could you be?

Yes
No
In the process

Have you experienced miscarriage(s) or a difficult pregnancy, childbirth or postpartum?

Yes
No

Are you prone to high blood pressure?

Yes
No
In the past

Are you prone to low blood pressure?

Yes
No
In the past

Do you own a cardiac pacing device?

Yes
No

Have you ever had an operation or been hospitalized?

Recently
No
In the past

Medication taken in the last year & reason(s) (prescription or over-the-counter)

Supplements taken in the last year & reason(s)

Therapist(s) seen in the last year & reason(s)

What is your relationship with the feminine & masculine and what place do they occupy in your life?

What is spirituality for you?

How do you take care of your physical, emotional and spiritual bodies?

Varias: details, questions, state of mind or anything else you'd like to share with me