Consultation Form

Please provide honest and detailed responses. All personal information is exclusively used by our holistic quantum healing center to ensure precise and proper services. Your data will not be shared with any external organizations.

Full Name

Date of Birth

Gender

Female

Male

Contact Number

Married / Civil relationship

Children

What is your eye and hair colour? What is the condition of your tongue? Are your average build thin or overweight? How would you describe yourself as a person? How do you think other people see you? Describe your relationships with any member of your family.

Is your body temperature generally cold, average, or hot? Is there a noticeable temperature difference or other sensation in, for example, your feet or hands or other body parts? How are your energy levels during the day, in the morning, midday, and evening time? How do collars, belts, and tight clothing affect you?

How do you feel before/during, or after meals? What foods do you have a strong liking and disliking for?

Which season do you feel best and worst? How do you feel in cold/dry/wet weather? Does the wind affect you? Do you mind the sun? Do you like storms and lightning? How do you respond to extremes of temperature? What kind of climate would you choose to spend your vacations in? Do you prefer mountains, woodland, seaside, hot and dry or humid climates? Do you keep a window open at night or during the day?

When conscious of your emotional and mental states during the day, can you describe what is predominant? Do you dream at night? If so, what are your dreams, and do they recur? What were the deepest griefs in your life? How do you cope with worries, concerns, and problems? Which or what kind of activity brings peace to your state of mind and emotions? Can and do you cry? What effect does consolation have on you? Do you ever feel jealous? Do you ever feel frightened or anxious? How are your memory, understanding, and concentration?

Describe in your own words, as you experience them, your symptoms. How long have you had the problem(s)? Describe any important events in your life recently or a long time ago. How do you feel about these events now? Describe anything strange or unusual about your current symptoms.

Has a diagnosis been made for your condition? Are you taking any other medication? If Yes, please give briefly information. Other therapies and self-help. What other therapies are you having or have you tried? Do you take any health food supplements? What types of activity or practice do you use to improve your health and vitality?

How was your birth experience? Outline your medical history in chronological order starting from as early as you can remember. List any recurrent health problems. Describe your family/ ancestral medical history, i.e. your mother's and father's health, for example.

Do you smoke or drink alcohol? If Yes, how often? Do you take any unprescribed drugs? Do you have any skin problems, or have you had them in the past? If so, describe them and how they were treated. Please define any other issues with any body part or function. How are your vision, hearing, and smell? Do you have, or have you ever had, any dental problems? Is there anything else that you feel would be worth mentioning?

Do you have any menstrual troubles? Please describe any significant symptoms. Please describe your period duration, abundance, odour, and colour. Describe your feeling or behaviour before, during, and after your period. How frequently do your periods come? Have you ever had, or do you have, problems in the area of your reproductive system?

Interests and hobbies. Describe any interests/hobbies and how they make you feel. How do you spend your spare time? Do you enjoy dancing? Are there any activities or sports that you often do?

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