Please answer the following questions using the form below:

1.   Home Address

2.   Date of Birth

3.   Age

4.   Occupation

5.   How did you hear about me?

6.   What is your marital status?   

7.   Describe the problems for which you    

      are seeking healing assistance

8.   How long have you had these

         problems?

9.   Do you smoke? If quit, how long ago?

10.  Please briefly state past medical 

          history including surgeries and

      accidents 

11.  What is your living situation? (alone,

        with parents, friend, animals) 

12.  What medications are you on?

13.   What health care professionals are

        you seeing now for this (these

        issues?

14.   How do you relax?

15.   How many hours do you sleep and is

       it restful?

16.   How is your stress related to:

       family, relationship, work, finances

       health, other?

17.   Are you having pain now?  If so,

       where is it located and what is the

       intensity of it with 10 being the

       worst?

 18.  Any other information you would            like to include that you feel will be            helpful
 

Below is the form you can use to send me the information I will need for your Dstance Healing Session.  If you have any questions just add them to the comments section.

To your left you will find the questions that I would like to have answered in order to better serve your needs.  You may answer by writing the specific number of the question and following with the answer.