Patient Forms

Name *

First Name

Last Name

Phone *

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Root Chakra *

Please select which you feel applies to you most today. If more than one applies to you, just choose whichever is most urgent right now.

Are you disorganized?

Do you eat, drink, or smoke excessively as a means of escape?

Did you have some trauma, distress, or difficulty between conception & age 7?

Do you feel fearful or anxious much of the time?

Are you low in energy and often feel weak, tired, or just not well?

Do you have any physical problems in your legs, knees, or feet?

Sacral Chakra *

Again, choose whichever one option feels most applicable to you today.

Do you have difficulty with touch; either being touched gently or being able to touch others?

Do you have problems with your kidneys, bladder, or with retaining fluid?

Did you suffer distress or trauma between the ages of 7 & 14?

Do you feel that your general vitality & stamina are low?

Do you have difficulties with any part of your sexuality?

Do you feel your creativity is blocked or that you are not a creative person?

Solar Plexus Chakra *

Choose which applies most to you today.

Do you have digestive problems, e.g. ulcers, heartburn, or recurrent indigestion?

Do you have an aggressive nature?

Did you suffer distress or trauma between the ages of 14 & 21?

Are you easily influenced?

Do you sometimes feel powerless or have a low self-esteem?

Heart Chakra *

Choose which most applies to you today.

Do you find it difficult to love or feel loved?

Are you intolerant, critical, or judgmental?

Do you feel exhausted & drained most of the time?

Are you impatient, or the opposite, i.e. so patient & tolerant that people take advantage of you?

Do you have difficulty in saying you are sorry or in feeling forgiveness?

Throat Chakra *

Please select just one that feels most like you today.

Do you have difficulty with general communication?

Do you have problems expressing yourself with speech, with making yourself understood clearly?

Do you have problems listening attentively to other people's point of view?

Do you have problems with throat infections, thyroid, ears, or neck problems in general?

Are you shy, quiet, withdrawn?

Third Eye Chakra *

Please select which one feels most like you today.

Do you suffer from migraine, vision problems, or headaches?

Are you unable to visualize the future?

Do you have nightmares?

Do you have a lack of imagination?

Do you have difficulty concentrating?

Crown Chakra *

One last time, please choose whichever feels most like you today.

Do you feel separated from abundance & wholeness?

Do you have difficulty learning new things?

Do you feel uncertain or feel a lack of purpose?

Do you have a fear of death?

Are you overly intellectual?