Date:
Name:
Address:
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Postcode:
Tel Home:
Tel Mobile:
Tel Work:
Email:
Energy Excellence is a training – not a therapy, treatment
or a magic pill, so it is important that you understand you must
apply the training to get the results you want. Just like someone
who goes to the gym and receives instruction from a coach on how
to use the equipment, the coach cannot lift the weights for you.
(Energy Excellence training does not involve gym machines!)
It is important that you are ready to commit to some initial hard
work to get well – if you are, please complete and return
this form. Upon receiving your form my assistant will call you to
make an appointment for us to have a chat so that you may ask any
questions and we can ascertain whether you are suitable for the
training and that the training is suitable for you.
Sex M / F
Age and Date of Birth:
Current or previous occupation:
What condition are you suffering from? (include
medical name/diagnosis if relevant)
Have you been diagnosed by a Doctor? Yes / No
How long have you had the condition and how did it start?
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How has this affected your life?
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On a scale of 1 to 10, how much does anxiety play a part
in your condition, where 10 is regular panic attacks?
On a scale of 1 to 10, how much does physical pain play
a part in your condition, where 10 is very high?
What do you want to achieve from doing the training?
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Do you understand that your mind, emotions and body can
influence each other in a negative or positive way? Yes/No
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Name 10 things you are looking forward to enjoying when
you are well
(these should be realistic achievable things you want)
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Your beliefs around your health:
How much do you agree with the following statements, on
a scale of 1 - 5, where 5 is "I totally agree":
* I want and desire to be healthy - 1 2 3 4 5
* I believe it is possible for me to be healthy - 1 2 3 4 5
* I have the capability to learn how to be healthy - 1 2 3 4 5
* Now is an appropriate time in my life to be healthy - 1 2 3
4 5
* The gains of being healthy outweigh the gains of remaining ill
- 1 2 3 4 5
* I am willing to change negative lifestyle habits and thought
patterns - 1 2 3 4 5
* Once I have been trained, I then hold the responsibility to
apply it to my life - 1 2 3 4 5
* I deserve to be healthy - 1 2 3 4 5
Knowing yourself better than anyone else, in what ways
could you ruin this opportunity to be well?
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What would you need to do to make sure the above does not
happen?
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What state of mind will you bring to the course and what
will you expect of yourself during and after the training to get
the results you want?
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Do you directly or indirectly know someone who has attended
a course with me to get well and if not, how did you hear about
me?
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Ability Scale (For Fatigue Disorders)
(Adapted from the Karnofsky Scale by Jill Moss in her book "Somebody
Help ME")
Please put an X in the box next to the description that best describes
your current ability.
Note: These categories give us a general idea of your current ability,
we realise you may fluctuate, but please indicate where on the scale
you have been on average over the last few months.
[ ] 100% No symptoms even following physical or mental exertion.
Able to study full time without difficulty, plus enjoy a social
life.
[ ] 95% No symptoms at rest. Mild symptoms following physical or
mental exertion - tire rather easily but fully recovered next day.
Able to study full time without difficulty but it means a slight
restriction on social life.
[ ] 90% No symptoms at rest. Mild symptoms following physical or
mental exertion - tire easily. Study full time with some difficulty.
Social life rather restricted.
[ ] 80% Mild symptoms at rest, worsened by physical or mental exertion.
Full time study at school or college difficult, especially if it
is a crowded, noisy environment. Home tuition or part-time study
without difficulty.
[ ] 70% Mild symptoms at rest, worsened by physical or mental exertion.
Daily activity limited. Part time study at school/college tiring,
restricting social life. With home study and careful pacing of activities,
some social life is possible. Careful exercise may be possible:
walking/swimming/cycling.
[ ] 60% Mild to moderate symptoms at rest. Increasing symptoms
following physical or mental exertion. Daily activity very limited,
although gentle walking/swimming/cycling is possible. Unable to
study with others. Short (1 or 2 hours) daily home study is possible.
Quiet, non-active social life possible.
[ ] 50% Moderate symptoms at rest. Increasing symptoms following
physical or mental exertion. Regular rest periods needed. Simple,
short home study possible when alternated with quiet, non-active
social life. Not confined to the house but unable to walk much further
than 200yds. Enjoy a trip to the shops in the wheelchair.
[ ] 40% Moderate symptoms at rest. Moderate to severe symptoms
following physical or mental exertion. Not confined to the house
but unable to walk much more than lOOyds. Can manage a wheelchair
outing to the shops on a quiet day. Requires three or four regular
rest periods during the day. Only one large activity possible per
day - friend dropping by or doctor's visit or short home study etc.
Rest of the time spent pottering around.
[ ] 30% Moderate to severe symptoms at rest with possible weakness
in hands and arms. Severe symptoms following any physical or mental
exertion. Usually confined to the house but enjoy a quiet wheelchair
ride or a gentle walk in the fresh air. Most of the day resting,
although some small tasks possible (e.g. letter writing). Mental
concentration poor and home study very difficult indeed.
[ ] 20% Fairly severe symptoms at rest. Weakness in hands, arms
or legs may be restricting movement. Unable to leave the house except
rarely. Confined to bed/settee most of the day but able to sit in
a chair for short periods. Unable to concentrate for more than one
hour a day.
[ ] 10% Severe symptoms at rest. In bed the majority of the time.
No travel outside the house. Concentration very difficult indeed.
[ ] 0% Severe symptoms on a continuous basis. In bed constantly.
Unable to Sit up. Unable to care for yourself.
Terms and Conditions of Training:
Agreement
I understand that Energy Excellence is a training, not
a treatment or therapy and if required, I am prepared to do the
initial hard work of changing any mental, emotional or physical
habits that may be preventing my full health. I understand that
Energy Excellence does not guarantee any results and I agree to
accept full responsibility for the effects of applying or not applying
this training.
Training and Payment Details
The training takes place over three consecutive days and
is taught as a group course which has a relaxed and friendly atmosphere.
The cost is £590. You will also need to budget for your travelling
and accommodation expenses.
Conditions of Payment
Fees become payable one month prior to the course. We regret
that fees cannot be refunded in the event of a cancellation on your
part. This is because we run group trainings with limited spaces.
If you take up a space and cancel, no one else will be able to fill
it at short notice.
Intellectual Copyright
The Energy Excellence course documents given to you as
part of the training are not to be reproduced, sold or distributed
in anyway.
I understand and agree to all the above conditions.
Signature:
Date:
Thank you for your time – we look forward to speaking with
you.
Please send to:
R. Amir Norris,
Fatigue Answers,
Innisfree House,
The Green,
Llansteffan,
Carmarthen SA33 5LW
UK
amir@fatigueanswers.com
0845 128 5228 / 01267 241740/ +44 1267 241740
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