This form is designed to help me assess your current and past health-related issues, in particular those illnesses and symptoms that are related to stress, and to help you start thinking about the health goals you would like us to work on during our time together. These results are completely confidential and will not be shared outside of this program. If you prefer to answer some or all of these questions once we meet in person, I encourage you to leave those sections blank.
If you have any questions, please contact me at Jill@JillWener.com.
What is your name?
What is your phone number?
Preferred contact method
How did you hear about Conscious Health Ally?
Friend (please list name below)
Social media (please list which type below)
Doctor or other healthcare professional (please list name below)
Internet search (please indicate which search engine below)
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