Client Questionnaire | Healing and Homeopathy | Worldwide Distant Healing Consultations

Please return this questionnaire at least one day before your initial consultation. The information that you provide is completely confidential, and will only be read by Marc Blausten.

PERSONAL INFORMATION

Name*

Address*

Street Address City County / State / Region ZIP / Postal Code Country

Mobile Phone*

Home Phone*

Email*

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Skype

Date of Birth*

Occupation*

Relationship Status*

Children*

How did you find us?

Google
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PHOTOGRAPH

Please upload a recent photo of yourself. Required for Distant Healing. Allowed file types are: jpg, gif, png, pdf, docx, doc

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MEDICATION

List any current medication. Include contraception and any other routinely taken medicines.

Drug Name*

Reason*

Date Started*

MEDICAL HISTORY

List all major illness’s, injuries and times hospital in chronological order : Please include births, and any recurring infections or conditions.

Age*

Condition*

Treatment*

GENERAL

Please describe what you would like assistance with.*

What have been the main stresses in your life - past and present?*

What was your childhood like?*

Any other information that you think might be useful?*

Data Privacy

This form collects your name, telephone number and email address along with your message so that our team can communicate with you and provide you with assistance. Please check our Privacy Policy to see how we protect and manage your submitted data.

I consent to my submitted data being collected and stored

Comments

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