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Oberon Health Assessment Form

Welcome to your Oberon health assessment form. Before we begin your scan, this form helps me understand your health history, daily habits, and any concerns you may have. It’s an essential step to make your session truly personalised and effective.

Your responses will guide us in uncovering underlying imbalances—whether they relate to physical health, emotional well-being, or energetic blockages. The Oberon scan looks at your body as a whole, and the more insight we have, the clearer your path to healing becomes.

Please take a few minutes to fill out the form with care. Your information will remain strictly confidential and will be used only to support your wellness journey.

Together, we’ll explore what your body is really telling you and take confident steps towards greater balance, vitality, and well-being.

Personal Information:

Name:

First Last

Date of Birth:

MM slash DD slash YYYY

Age:

Email:

Phone:

Address:

Street Address City State / Province / Region ZIP / Postal Code Country

Occupation:

Blood type:

Relationship:

Primary Health Concerns:

What are your main reasons for seeking an Oberon scan?

Current Symptoms & Health History:

Please list any current symptoms, discomfort, or concerns (check all that apply and provide details):

Fatigue / Low Energy

Sleep Issues (insomnia, poor quality, waking up often)

Digestive Problems (bloating, gas, constipation, diarrhea, acid reflux)

Joint or Muscle Pain (hips, shoulders, back, knees)

Headaches / Migraines

Skin Issues (acne, eczema, dryness, rashes)

Hormonal Imbalances (menopause, irregular cycles, PMS, thyroid issues)

Mood Changes (anxiety, depression, irritability, stress)

Weight Fluctuations (gain/loss, difficulty losing weight)

Food Sensitivities / Allergies

Immune Weakness (frequent colds, infections)

Other

other:

When did these symptoms start?

Have you tried any medication, treatments, detoxes, or therapies for these concerns? If yes, please list:

Lifestyle & Daily Habits:

On average, how many hours of sleep do you get per night?

Do you feel rested upon waking?

Yes

No

How would you rate your stress levels?

Low

Moderate

High

Do you drink alcohol?

Yes

No

If yes, how often?

Do you smoke?

Yes

No

If yes, how often?

How much water do you drink daily? (liters / glasses)

Do you consume caffeine?

Yes

No

If yes, how often?

Do you exercise?

Yes

No

If yes, what type and how often?

Diet & Nutrition:

Do you follow any specific diet (vegan, keto, gluten-free, etc.)?

Do you eat processed or fast food regularly?

Yes

No

How many servings of vegetables do you eat daily?

Do you experience cravings for certain foods?

Yes

No

If yes, which ones?

Medical History:

Are you currently taking any medications or supplements? If yes, please list:

Have you had any major surgeries or hospitalizations? If yes, please provide details:

Any history of family illness (cancer, diabetes, heart disease, etc.)?

Emotional & Energetic Well-Being:

How do you currently feel emotionally?

Balanced

Stressed

Overwhelmed

Low

Have you experienced any major emotional trauma or stress in the past year?

Yes

No

Do you practice mindfulness, meditation, or relaxation techniques?

Yes

No

Additional Notes:

Is there anything else you would like to share about your health or lifestyle?

Client Agreement & Consent:

I acknowledge that the Oberon scan and holistic wellness approach provided is not a substitute for professional medical advice, diagnosis, or treatment. I consent to the scan and understand that results are for informational purposes only.

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