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Would you like to be prayed over at the beginning of the appointment?
Yes please!
No thanks
Are you open to discussing the emotional and spiritual pieces that we find during the session?
Yes
No

Please rate the following symptoms - 1= none / 5=high, all the time and give a brief description of your symptoms and concerns

Pain Level
1
2
3
4
5
Energy level
1
2
3
4
5
Sleep Quality
1
2
3
4
5
Digestive Complaints
1
2
3
4
5
Skin issues, (acne, eczema, rash, dryness etc..)
1
2
3
4
5
Brain/Memory issues
1
2
3
4
5
Respiratory/Breathing
1
2
3
4
5
Stress/anxiety
1
2
3
4
5
Depression
1
2
3
4
5
Frequent illness/poor immunity
1
2
3
4
5
Weight gain/ inability to lose weight
1
2
3
4
5
Inability to gain or maintain weight
1
2
3
4
5
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