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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you had energy healing before?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

Please elaborate in detail the reason for your session.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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