TeleHealing Registration

TeleHealing Registration

August 4, 2024 | 10pm to 11:30pm Philippine Time
Step 1 of 2 : Complete the TeleHealing Client Intake Form

CONFIDENTIAL
Who is enrolling for TeleHealing?

I am enrolling myselfI am enrolling someone else
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Mobile Phone*
E-mail*
example@example.com
Who recommended you? How did you find out about TeleHealing?
How may we help you? Please mention reasons for enrolling into our program.*
Personal Information
Marital Status
Number of children, if any
Employment status
Occupation/Career
Name of employer, if applicable
Tell us about your Overall Health and Habits
Do you consume*

TeaCoffeeTobaccoAlcoholPrescription DrugsRecreational Drugs
Does your diet include*

BeefPorkChickenSeafoodVegetablesDairy ProductsOther
Specify any recreational or prescription drugs you are taking:
How often do you exercise?*
What exercise/s do you do?
What is your weight goal?
My current weight is:
Physical Health Status (check all that apply)

High Blood PressureLow Blood PresureHeart DiseaseAsthmaSpinal IssuesCancerDiabetesAnemiaBleedingInternal OrgansAddictionLearning DisabilitiesEpilepsyVertigoMigraineInfertility/ConceptionPeri-menopauseMenopausePainFatigueOther

Total Health Status (rate yourself)*

	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Physical Health
Vitality and Energy Level
Emotional Stability
Mental Attitude and Clarity
Religious/Spiritual/Inner Alignment

General Quality of Life (rate yourself)*

	1-Poor	2-Fair	3-Good	4-Very Good	5-Excellent
Relationships at Home
Relationships at Work
Social Relationships
Job/Role Satisfaction
Quality of Rest/Relaxation
Ability to Manage Stress
Quality and Time for Recreation
Financial/Material Life
Level of Success
Level of Self-Fulfillment in Life

Psychological Status*

	Yes	No
Fear/Phobia
Anger/Frustration
Anxiety/Worry
Sadness/Loneliness/Grief
Guilt/Self-Pity
Resentment/Pent-up Emotions
Lack of Self-Confidence/Self-Esteem
Laziness
Lack of Motivation/Purpose
Slowness in Action/Indecisiveness
Psychological Depression
Suicidal Tendency
Self-Destructive Behavior
Anti-Social/Oppositional Tendency
Vice/Addiction
Compulsion/Obsession
Trauma/Post-Traumatic Issues
Shame
Abused/Victim
Abuser

Please describe any other psychological issues you may have or give additional information related to the items you have checked above.
COVID-19 Status
Have you had COVID-19 Infection?

YesNo
If you have tested positive for COVID-19, please provide the following information. Otherwise, you may skip to the next section.
Date of infection/exposure (if known):
Date when symptoms started:
Date of Positive COVID-19 test:
Name of attending physician:
Name of clinic/hospital of testing or confinement:
Date of related hospitalization if any:
COVID-19 Symptoms Experienced

ColdDry coughRunny or stuffy noseMalaise/fatigueFeverBody acheDifficulty breathingBronchitisPneumoniaAcute Respiratory Distress Syndrome (ARDS)NauseaDiarrheaPressure or pain in chestBluish face or lipsLoss of taste/smell
Please upload your recent picture

Full body picture is preferable
Upload your recent picture*

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DISCLAIMER/WAIVER I understand that TeleHealing and World Institute for Incurable Diseases (WIID) programs do not claim to supplant or replace medical or psychological treatment. I understand that TeleHealing, WIID Specialists and MDP Ashram Inc. services do not diagnose any health or psychological conditions. I hereby forever release and hold TeleHealing, World Institute for Incurable Diseases, MDP Ashram Inc., Master Del Pe and all of its officers, agents, employees, directors, executives, managers, successors and licensees harmless from any and all liability, encumbrances or responsibility for the outcomes of services provided. Everything I have written and answered is true and correct.
Signature*

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Full Name*
Date Signed*

MonthDayYear
Date
Payment

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TeleHealing Registration

Step 1 of 2 : Complete the TeleHealing Client Intake Form

Personal Information

Tell us about your Overall Health and Habits

COVID-19 Status

Please upload your recent picture

Payment