Energy Recovery Consultation Form

The energy recovery form is a prelude to any of my health programs.  This will give me a good idea of your lifestyle and places of unbalance.  After this form is filled out you will receive your free 20 min email consultation and a complimentary daily protocol handout. 

 

All information documented is strictly confidential and will not be shared!   

Take advantage today since this offer will only be available for a short time. 

These questions will give me a better understanding of any health issue you are facing. The best answer is the first one that comes to your mind. Don’t over think it! It is meant to be simple and informative…


arthritis
blood clots
broken or dislocations
bruise easily
cancer
chronic pain
headaches
insomnia
high blood pressure
heart conditions
seizures
scoliosis
constipation/diarrhea
auto-immune conditions (aids, fibromyalgia, chronic fatigue, lupus etc...)
skin conditions (Note if it is a daily issue)
stroke
surgery
back problems
depression, pain disorder, other psych

Enter a number between 1-10. #10 meaning good health - #1 meaning severe pain or cancers




Normal
Dry/Sensitive
Oily
Combination

Put an X for the answers that are true today and put a P next past challenges:

HOT & COLD

DRY & DAMP

MORE SPECIFICS

High but sporadic
Moderate yet constant
Low or sluggish

High
Moderate
Low

Yes
No

Anxiousness
Anger
Withdrawal

Low back and legs
Torso and mid-back
Head, neck and shoulders

Light and energetic
Strong and firm
Heavy and sluggish