Name *

First Name

Last Name

Phone *

(###)

###

####

Are you disorganized? *

Yes

No

Do you have a tendancy to escape using one of the following? *

eat

drink

smoke

none

Did you have some trauma, distress or difficulty between conception up to the age of 4? *

Yes

No

Do you feel fearful or anxious much of the time? *

Yes

No

Do you experience ..... *

low energy

often feel weak

tired

just don't feel well

all of the above

no problems at all

Do you have any physical problems in your ... *

feet

ankles

knees

legs

none of the above

Do you have difficulty with touch .... *

being touched gently

being able to touch others

no problems & love to hug

Do you have problems with ... *

kidneys

bladder

retaining fluids

hips

no problems at all

Do you have some trauma, distress or difficulty between ages 4-7? *

Yes

No

Do you feel that your general vitality and stamina are low? *

Yes

No

Do you have difficulties with any part of your sexuality? *

Yes

No

Do you feel .... *

your creativity is blocked

not a creative person ever

enjoy being creative (write, art, work with hands)

Do you have digestive problems? *

ulcers

heartburn

indigestion

constipation

feel great!

Did you have some trauma, distress or difficulty between the age of 7-11? *

Yes

No

Are you easily influenced? *

Yes

No

Do you sometimes feel powerless or have low self-esteem? *

Yes

No

Do you find it difficult to love or feel loved? *

Yes

No

Are you .... *

intolerant

critical

judgmental

none of above

Do you feel exhausted and drained most of the time? *

Yes

No

Are you ... *

impatient

too patient & tolerant that people take advantage of you

neither

Do you have difficulty in saying you are sorry or forgiving someone? *

Yes

No

Do you have difficulty with general communication? *

Yes

No

Do you have a problem with expressing yourself with speech, with making yourself understood clearly? *

Yes

No

Sometimes depending on topic

Do you have problems listening attentively to other people's point of view? *

Yes

No

Do you have problems with.... *

throat infections

thyroid

ears

neck problems

no problems

Are you .... *

shy

quiet

withdrawn

none of the above

Do you suffer from ... *

migraines

vision problems

headaches

none of the above

Are you able to visualize your future? *

Yes

No

Do you have nightmares? *

Yes

No

Do you have a lack of imagination? *

Yes

No

Do you have a difficulty concentrating? *

Yes

No

Do you feel separated from abundance and wholeness? *

Yes

No

Do you have difficulty learning new things? *

Yes

No

Do you feel uncertain or feel a lack of purpose? *

Yes

No

Do you have a fear of death? *

Yes

No

Are you overly intellectual? *

Yes

No