Please enable JavaScript in your browser to complete this form.Client Contact Information - Step 1 of 4Name *FirstLastDate *Phone *Email *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryNextHealth Related Quality Of Life QuestionnairePlease answer the questions on a scale of 1 to 10. 1 representing that you do not agree with the statement and/or NEVER experience this health factor and 10 representing that there is no doubt in your mind or heart that you agree with the statement and/or experience this health issue factor consistently.[1] = Absolutely Disagree, [2] [3] [4] [5] = Neutral, [6] [7] [8] [9] [10] = Absolutely AgreeIn general, my breathing is deep and easy. Your Selected Answer: 1In general, movement is easy. Your Selected Answer: 1In general, standing straight is easy. Your Selected Answer: 1My overall posture is good. Your Selected Answer: 1In general, I feel my spine or areas of my spine to be at peace. Your Selected Answer: 1My body is effective at avoiding and holding tension. Your Selected Answer: 1My body is effective at releasing tension. Your Selected Answer: 1I have experienced a sensation of my spine "self-adjusting" during a session. Your Selected Answer: 1I have experienced a sensation of my spine "self-adjusting" outside of a session. Your Selected Answer: 1NextPlease rate the following quality of life factors on a scale of 1-10. 1 being the worst, and 10 being the best.[1] = The Worst, [2] [3] [4] [5] = Neutral, [6] [7] [8] [9] [10] = The BestPhysical State[1] = The Worst, [2] [3] [4] [5] = Neutral, [6] [7] [8] [9] [10] = The BestPresence of physical pain. Your Selected Answer: 1Feeling of tension or stiffness or lack of flexibility in your spine. Your Selected Answer: 1Fatigue or low energy. Your Selected Answer: 1Incidence of colds or flu. Your Selected Answer: 1Please explain:Mental/Emotional State[1] = The Worst, [2] [3] [4] [5] = Neutral, [6] [7] [8] [9] [10] = The BestDistress about your physical state. Your Selected Answer: 1Feelings of self-esteem. Your Selected Answer: 1Emotional balance and well-being. Your Selected Answer: 1Depression Your Selected Answer: 1Anxiety Your Selected Answer: 1Ability to concentrate, focus. Your Selected Answer: 1Ability to take responsibility for areas of my life. Your Selected Answer: 1Ability to Handle External Stress[1] = The Worst, [2] [3] [4] [5] = Neutral, [6] [7] [8] [9] [10] = The BestSignificant Relationship Stress Your Selected Answer: 1Work or School Stress Your Selected Answer: 1Family Stress Your Selected Answer: 1Please ExplainLife Enjoyment[1] = The Worst, [2] [3] [4] [5] = Neutral, [6] [7] [8] [9] [10] = The BestOpenness to guidance to your inner voice/feelings. Your Selected Answer: 1Experience of relaxation or ease of well-being. Your Selected Answer: 1Interest in maintaining a healthy lifestyle. Your Selected Answer: 1Connection with others. Your Selected Answer: 1Feelings of compassion towards others. Your Selected Answer: 1Feelings of responsibility towards environment. Your Selected Answer: 1Ability to forgive others and myself. Your Selected Answer: 1Connection with myself. Your Selected Answer: 1Feelings of compassion towards myself. Your Selected Answer: 1Please ExplainNextPart 2The work I do is intuitive in nature. However, it is informed by my experience as a health practitioner. I am purposely not asking many questions in order to give us a chance to uncover what needs to be addressed during each unique session. This said, I’d like to hear more about you, your intentions and a little bit of your history.Please answer the following questions.Please share any comments about your overall experience:How can we improve our services?Is there anything else you would like to share with us?May we share your comments for educational and promotional purposes?YesNo- May we use your name, initials, or anonymity in association with your comments?OK to use my nameOK to use my initials- Please write your name or initials as you would like them to appear.Thank you!~JulietaEmailSubmit
