Intake form – Villa O

Just your name and a valid e-mail, and we're good to go.

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Step 1 of 9

Hello, nice to meet you!

A few basics first. Only your name and e-mail are required, so skip anything you'd rather not answer.

Your name *

E-mail *

Phone

Date of your session (if you know)

Date of birth

Place & country of birth

Height (cm)

Weight (kg)

Gender

Female Male X Prefer not to say

Your home situation

Living together / married, with children Living together / married, no children Single with children Single without children Co-housing Living with parents or children

Your work situation

Employed full time Employed part time Self-employed / freelance Looking for work Student Homemaker / parental leave Retired Unable to work (illness / disability)

Great start!

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Step 2 of 9

Your story so far

A little time travel. “I don't know” is a perfectly good answer here.

How did you come into this world?

Natural birth C-section I don't know

Were you breastfed?

No, baby formula Yes, less than 1 month Yes, 1 to 3 months Yes, more than 3 months I don't know

Roughly how many times in your life have you had the following? A good guess is fine.

Antibiotic treatments

0 1 2 3 4 5+

Bacterial infections

0 1 2 3 4 5+

Viral infections

0 1 2 3 4 5+

Chronic illnesses

0 1 2 3 4 5+

Operations under general anaesthesia

0 1 2 3 4 5+

Fractures

0 1 2 3 4 5+

Physical trauma / accidents

0 1 2 3 4 5+

Electric shocks

0 1 2 3 4 5+

Vaccinations

0 1 2 3 4 5+

Exposure to chemicals or toxic products

0 1 2 3 4 5+

Parents exposed to chemicals or toxic products

0 1 2 3 4 5+

Exposure to radiation

0 1 2 3 4 5+

Implants / implanted technology

0 1 2 3 4 5+

Have any organs been (partly) removed?

Gallbladder Tonsils Appendix Spleen Thyroid (part or whole) Kidney Lung (part) Stomach reduction / bypass Colon reduction / bypass Womb Ovary / ovaries Other reproductive organs None Other…

Nice, you're on a roll.

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Step 3 of 9

How does your body feel lately?

Tick whatever shows up now and then. No judgement: bodies are complicated (and wonderful).

⚡ Energy & mind

Low energy Chronic fatigue Energy dips during the day Brain fog / unclear thinking Feeling low / down Fear or anxiety Dizziness / fainting Headaches / migraines

🥗 Digestion

Low appetite Food cravings Bloating Flatulence Constipation Diarrhoea Nausea / vomiting Clay-coloured stool Haemorrhoids Dull pain on the right side (under the ribs) Tooth or gum problems

💪 Muscles & joints

Stiff neck Shoulder or back pain Pain at or between the shoulder blades Lower back pain Joint problems Gout Cramps Loss of muscle tone Numbness in arms or legs Swollen legs, knees or feet

✨ Skin, eyes & hair

Skin problems Itching Pale complexion Yellowish eyes or skin Dark circles under the eyes Puffy eyes Vision problems Greasy hair / hair loss

🌙 Hormones & more

Hormonal imbalance Menstrual pain Menstrual or menopausal complaints Hot / cold flushes Impotence Urinary problems Cold hands or feet Breathing difficulties Coughing Excess weight

Anything else? Or your main complaint in your own words

If relevant: do you use contraception?

Hormonal (pill, ring, hormonal IUD...) Non-hormonal (copper IUD, condom...) No Not applicable

If relevant: your cycle

Regular Irregular (Peri)menopause Not applicable

Thanks for being so open.

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Step 4 of 9

Medication & safety

This helps us pick the right therapies for you and keep everything safe and comfortable.

Which medication do you take currently or regularly?

Painkillers Anti-inflammatories Fever reducers Sleeping pills Tranquillisers / anti-anxiety Antidepressants Antipsychotics Blood thinners Blood pressure medication Heart medication Cholesterol medication Diabetes / insulin Thyroid medication Antacids / stomach protectors Laxatives Anti-diarrhoea Anti-nausea Antibiotics Antivirals Antifungals Antihistamines / anti-allergy Inhalers / bronchodilators Cough or cold remedies Diuretics Immunosuppressants Cancer treatment Muscle relaxants Hormonal contraception Hormone therapy (HRT, testosterone...) Vitamins / supplements None

Names and doses, plus any supplements (if you have them handy)

Does any of this apply to you? (Important for some of our therapies.)

Pacemaker or other implanted electronic device Metal implants or prostheses Pregnant or possibly pregnant Breastfeeding Epilepsy Recent ear, sinus or lung problems Claustrophobia Serious heart condition Currently treated for cancer Surgery in the last 3 months None of these

Is a doctor or therapist currently following you for a health issue?

Yes No

If yes, for what? (optional)

Almost halfway. Sip of water? 💧

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Step 5 of 9

Stress & mood

Let's check the weather inside. Sunny, cloudy, a bit of both?

How high is your stress level these days?

😐?

0 · Zen masterPressure cooker · 10

What affects your stress level?

Family Relationship Work Colleagues Money worries Social insecurity Loneliness People in general News / media Environment and climate Weather Lifestyle Negative emotions Unprocessed emotions Psychological tension Conflicts / discussions Other…

How do you usually deal with stress?

Exercise Walking / nature Meditation / breathing Yoga Music Dancing / singing Talking with friends Sleep Food TV / series Phone / social media Sex Alcohol Smoking Drugs Medication Other…

How happy do you feel overall?

🙂?

0 · Rainy dayOver the moon · 10

And your energy level?

🙂?

0 · Flat batteryFully charged · 10

Have you ever been diagnosed with a mood disorder (depression, burnout, bipolar...)?

Yes No I don't know

Do you sometimes feel something “heavy” or foreign weighing on you energetically?

Yes No Not sure

💛 Going through a really tough time? Please talk to your doctor too. In an emergency call 112, or the suicide prevention line 1813 (Dutch) or 0800 32 123 (French).

Halfway there! 🎉

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Step 6 of 9

Your daily rhythm

Coffee counts. So does chocolate. Honest answers get the best advice. 😉

💧 How much still water do you drink on an average day?

Less than 0.5 L 0.5 to 1 L 1 to 1.5 L 1.5 to 2 L More than 2 L

Roughly how many portions per day?

Sparkling water

0 1 2 3 4 5+

Soft drinks (cola, lemonade, iced tea...)

0 1 2 3 4 5+

Coffee

0 1 2 3 4 5+

Tea

0 1 2 3 4 5+

Energy drinks

0 1 2 3 4 5+

Cow's milk

0 1 2 3 4 5+

Plant-based milk

0 1 2 3 4 5+

Fruit

0 1 2 3 4 5+

Vegetables

0 1 2 3 4 5+

Animal protein (meat, fish, eggs...)

0 1 2 3 4 5+

Carbohydrates (bread, pasta, rice, pastries)

0 1 2 3 4 5+

Sweets (candy, biscuits, cake, ice cream...)

0 1 2 3 4 5+

Wine

0 1 2 3 4 5+

Beer

0 1 2 3 4 5+

Spirits

0 1 2 3 4 5+

How many days a week do you...

Exercise or play sports

0 1 2 3 4 5 6 7

Walk or spend time outdoors

0 1 2 3 4 5 6 7

Meditate

0 1 2 3 4 5 6 7

Take a sauna

0 1 2 3 4 5 6 7

Drink alcohol

0 1 2 3 4 5 6 7

Smoke

0 1 2 3 4 5 6 7

Spend 3+ hours on screens

0 1 2 3 4 5 6 7

What do you find hard to let go of? (Everybody has something!)

Sugar Coffee Alcohol Smoking / nicotine Drugs Food in general Phone / social media Internet TV / series Video games Work Exercise Shopping / money Gambling Sex Sleeping Nothing, I'm a saint Other…

You're doing great.

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Step 7 of 9

Heart & head

The questions that matter most. Answer as much or as little as you like.

How would you rate these relationships? (10 = wonderful)

Partner

😐?

n/a

Parents

😐?

n/a

Children

😐?

n/a

Other family

😐?

n/a

Friends

😐?

n/a

Colleagues

😐?

n/a

Is there something that keeps your mind busy all the time?

What's the one thing you'd most like to change in your life?

What are your biggest challenges right now?

What are your main goals or dreams?

Are there difficult experiences that still affect you? Share only what feels comfortable.

What are you most proud of?

What are you most grateful for?

What makes you happiest? What do you love doing?

What do you sometimes worry about?

The future Health / illness Death Money / financial security Work / job security Family Relationships People in general Bacteria / viruses Being overweight Being too thin How I look Being happy (yes, that's a thing) Being unhappy Good luck not lasting Other…

The deep questions are done. Breathe out. 🌬️

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Step 8 of 9

Sleep

Almost there! Let's talk about everyone's favourite activity.

How many hours do you sleep on an average night?

Less than 5 h 5 to 6 h 6 to 7 h 7 to 8 h More than 8 h

When do you usually go to bed?

Before 22:00 22:00 to 23:00 23:00 to midnight After midnight It varies a lot

Which of these often happen around your sleep?

Trouble falling asleep Waking up at night Waking up too early Restless sleep Nightmares Vivid dreams Snoring Sleep apnoea Teeth grinding Still tired when I wake up Tired during the day Need a nap during the day I sleep like a baby Other…

Last one, promise!

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Step 9 of 9

Your session

Last step! Tell us what you hope for, and we'll prepare everything with care.

What would you like to work on during your session?

What do you hope to feel or take home afterwards?

Which therapies are you curious about?

Bioresonance / biofeedback PEMF Hyperbaric oxygen Red light therapy Health coaching Energy therapy No idea, surprise me

Anything else you'd like us to know? Fun facts welcome.

How did you find Villa O?

Google Social media Friends or family Booking.com I stayed at Villa O Other

I agree that Villa O uses my answers, including health information, only to prepare my session, and treats them confidentially. *

Please tick the box above so we can receive your answers.

Thank you! 🌿

Your form is safely on its way to us. We'll read it with care before your session. See you soon at Villa O!

Good to know: we are not medical doctors. We don't make diagnoses, prescribe medication or advise you to stop a treatment. Our therapies support your wellbeing and complement, never replace, medical care, so please keep following your doctor's advice. Your answers stay confidential and are only used to prepare your session.

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