Date: Name: Address: . .
Postcode: Tel Home: Tel Mobile: Tel Work: Email: Please tick course type: The Energy Excellence Course 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. Applications are usually processed within a few days, then we will contact you with an indication as to whether we think the course is a good fit for you. Sex M / F Age and Date of Birth: Current or previous occupation:
Have you been diagnosed by a Doctor? Yes / No How long have you had the condition and how did it start? . . . . . How has this affected your life?
What other therapies/approaches have you tried? . . . . 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? . . . . . . Do you understand that your mind, emotions and body can influence each other in a negative or positive way? Yes/No . . . Name 10 things you are looking forward to enjoying when
you are well . . . . . . . . . . . .
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? . . . . . . . What would you need to do to make sure the above does not happen? . . . . . . 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? . . . . . . .
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? . . .
Ability Scale (For Fatigue Disorders) 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.
Agreement Training and Payment Details Date: Thank you for your time – we will process your application form as soon as possible. Please Email or Post to: amir@fatigueanswers.com |
